CMS-1500 Claim Form Instructions - JA DME

Insured's ID Number
(Medicare ID)
This is a required field. Enter the patient's Medicare ID whether Medicare is the primary or the secondary payer. An invalid Medicare ID will cause a claim to deny or be rejected as unprocessable.

• Group Health Plan Coverage
  • Working Aged (Type 12);
  • Disability (Large Group Health Plan - Type 43); and
  • End Stage Renal Disease (ESRD - Type 13);
• No Fault (Type 14) and/or Other Liability (Type 47); and
• Work-Related Illness/Injury:
  • Workers' Compensation (Type 15);
  • Black Lung (Type 41); and
  • Veterans Benefits (Type 42).

• Enter the drug's name, strength, and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
• Enter a concise description of an "unlisted procedure code" or a "not otherwise classified" (NOC) code within the confines of this box. An attachment may also need to be submitted to help expedite claim processing. If more than one unlisted procedure code is reported on the claim, precede each description in item 19 with the line item number that corresponds to the line that contains the NOC code. This will enable claims processing staff to determine the correct description for each unlisted procedure code. If billing the same unlisted procedure code more than once on the claim, you may need to indicate the charges of the procedure codes to indicate which description belongs to each line.
• Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in item 24D. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item. Modifier 99 is only appropriate when more than four modifiers are necessary per claim line. When four or less modifiers apply, each modifier can be entered in the existing space in item 24D on the CMS-1500 Form.
• Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a non-participating provider/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.

Patient's Diagnosis/Condition
Do not insert a period in the ICD-10-CM code.

• If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1), one UTN submitted per claim line

Procedures, Services, or Supplies Code
This is a required field.

Procedure Code: Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (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 description in item 19 if a coherent description can be given within the confines of that box.

• Narrative added to claim:
  • Description of the item or service
  • Manufacturer name
  • Product name, model name and number
  • Supplier Price List (PL) amount (this is the same amount billed on the claim line)
  • HCPCS code of related item (if applicable)
  • If Repair part, HCPCS code of item being repaired

Example

• Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), MSRP $XXX.XX
• Indicate what it is, what is it for, what is MSRP

Otherwise, an attachment must be submitted with the claim with additional information submitted.

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 with that information.

Modifiers: When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 Form has the ability to capture up to four modifiers. If more than four modifiers are needed, use modifier 99 (overflow) as the fourth modifier and enter the additional modifiers in item 19.

• Modifier placement
  • First position - Pricing modifiers. i.e. RR, KH, KI, KJ, NU
  • Second position - Modifiers to indicate requirements specified in the medical policy have been met. i.e. KX
  • Other positions - Any additional informational modifiers required
• Please utilize the Modifier Lookup Tool for reference on potential modifiers for HCPCS codes

Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits. Some modifiers cause automated pricing changes, while others are used to convey information only. They are not required on all HCPCS codes; however, if required and not submitted, the claim will deny as unprocessable. 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.

• Submit the service with an acceptable dollar amount (< 9999999.) See example below, splitting total. (Do not use dollar signs, decimals, dashes, commas for dollar amounts.)
• In the narrative field, identify this as, "Claim 1 of 2; Dollar amount exceeds charge line amount."

• Enter the charge as the remaining dollar amount from the total split.
• In the narrative field, identify this as, "Claim 2 of 2; Remaining dollar amount from Claim 1 amount exceeds charge line amount."

• Narrative must be added in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form in the narrative field.

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.