Claim Form Instructions - JE Part B

Type of Health Insurance Coverage Applicable to the Claim
This is a required field. 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.

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.

Patient's Name
This is a required field. Enter the patient's last name, first name, and middle initial, if any, as it appears on the patient's Medicare card (e.g., Jones John J). Include only one space between the last name, first name, and middle initial. If the name is not an identical match, the claim will be rejected as unprocessable.

Do not submit extra spaces, nicknames, or descriptions such as Jr., Sr., deceased, or the estate of (unless indicated on the Medicare card). Do not extend the beneficiary's name beyond the confines of this box.

Patient's Birth Date and Sex
Enter the patient's 8-digit birth date (MM | DD | CCYY) and sex. Only one box should be indicated; either M or F. Marking both or neither will cause the claim to be rejected as unprocessable.

Insured's Name
If Medicare is primary, leave blank. 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.

Patient's Address and Telephone Number
This is a required field and must be filled in completely.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.

Patient's Relationship to Insured
If Medicare is primary, leave blank. Check the appropriate box for the patient's relationship to the insured when item 4 is completed.

Insurance Primary to Medicare, Insured's Address and Telephone Number
Complete this item only when items 4, 6, 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.

Reserved for NUCC Use
Leave blank.

Medigap Benefits, Other Insured's Name
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 item 2. Otherwise, enter the word SAME. This field may be used in the future for supplemental insurance plans.

NOTE: Only Participating Physicians and Suppliers are to complete item 9 and its subdivisions and only when the Beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the Participating Physician or Supplier.

Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. (See chapter 28 of the Medicare Claims Processing Manual.)

Medigap - Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in §1882(g)(1) of title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.

Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the A/B MAC to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.

Medigap Benefits, Other Insured's Policy or Group Number
If no Medigap benefits are assigned, leave blank. Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP. Do not enter other types of insurance (e.g., supplemental).

NOTE: Item 9d must be completed if the provider enters a policy and/or group number in item 9a

Reserved for NUCC Use
Leave blank.

Reserved for NUCC Use
Leave blank.

Medigap Benefits, Insurance Plan/Program Name, PAYERID Number
Enter the nine-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

If the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, the participating provider or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d. Otherwise, the Medicare carrier cannot forward the claim information to the Medigap insurer. A Medicare participating provider or supplier shall only enter the COBA Medigap claimbased ID within item 9d when seeking to have the beneficiary's claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See chapter 28 §70.6.4 for more information concerning the COBA Medigap claim-based crossover process.)

NOTE: The configuration of the PAYERID is alpha numeric and up to 9 digits. Noridian assigns five digit alpha numeric or numeric PAYERID numbers rather than nine digit numbers.

Condition Relationship? Employment, Auto Liability, or Other Accident
Check "YES" or "NO" by placing an (X) in the center of the box to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES," indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD. Leave blank. Not required by Noridian.

Insured's Policy Group or FECA Number
Note: All claims can be submitted electronically. For more information, refer to EDISS website at https://www.edissweb.com

THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.

If there is insurance primary to Medicare for the service date(s), enter the insured's policy or group number within the confines of the box and proceed to items 11a-11c. Items 4, 6, and 7 must also be completed. If item 11 is left blank, the claim will be denied as unprocessable.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11.

If there is no insurance primary to Medicare, do not enter "n/a," "not," etc., enter the word NONE within the confines of the box and proceed to item 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 item 11b.

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word NONE in item 11 of the CMS-1500 Form, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.

Insurance Primary to Medicare- Circumstances under which Medicare payment may be secondary to other insurance include:

• 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).

NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a policy or group number must be entered in this item. In addition, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Pub. 100-05, Medicare Secondary Payer Manual, Chapter 3.) Without an attached EOB from the primary insurance, the claim will be denied.

Insured's Date of Birth and Sex
This item must be completed if a policy or group number is reported in item 11 AND is different from the date in item 3. Enter the insured's 8-digit birth date (MM | DD | CCYY) and sex if different from item 3.

Insurance Primary to Medicare, Employer's Name
Provide this information to the right of the vertical dotted line: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) retirement date proceeded by the word "RETIRED."

Insurance Plan/Program Name
This is required if there is insurance primary to Medicare that is indicated in item 11. Enter the nine-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer's program or plan name. 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. Please include the telephone number of the primary payer.

Leave blank. Not required by Medicare.

Patient's or Authorized Person's Signature
This is a required field. The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alphanumeric date (e.g., January 1, 2008) 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 in accordance with Chapter 1, "General Billing Requirements." If the patient is physically or mentally unable to sign, a representative specified in Chapter 1, "General Billing Requirements" 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, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient's representative revokes this arrangement.

NOTE: This can be Signature on File and/or a computer generated signature.

The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Medigap Benefits, Insured's/Authorized Person's Signature
The patient's signature or the statement "signature on file" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient's signature or a "signature on file" is not required in order for Medicare payment to be made directly to the physician or supplier. The presence of or lack of a signature or "signature on file" in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

NOTE: This can be "Signature on File" and/or a computer generated signature.

Date of Current Illness/Injury/Pregnancy

• For current illness, injury, or pregnancy, enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date.
• For chiropractic services, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of x-ray (if used to demonstrate subluxation) in item 19.

Additional information for form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in Item 14.

Leave blank. Not required by Medicare.

Dates Patient Unable to Work in Current Occupation
If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when the patient is unable to work.

An entry in this field may indicate employment related insurance coverage.

Name of the Referring or Ordering Physician
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each. Enter the physician's first name and last name only. An exact match with PECOS is required. If you cannot fit the entire name in the field, use the first initial of the first name and the entire last name. Do not use a credential (e.g., "Dr." or "M.D") in the field.

Additional instructions for form version 02/12: Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:

• DN - Referring Provider
• DK - Ordering Provider
• DQ - Supervising Provider

Enter the qualifier to the left of the dotted vertical line on Item 17.

NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to perform these roles. Refer to CMS IOM Publication 100-02, Medicare Benefits Policy Manual, Chapter 15 for non-physician practitioner rules. Enter non-physician practitioner information according to the rules above for physicians.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;
2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;
3. A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a), 1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;
4. A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or
5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §§1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished.

Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician's or non-physician practitioner's service.

The ordering/referring requirement became effective January 1, 1992, and is required by Section 1833(q) of the Social Security Act. All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See items 17a and 17b below for further guidance on reporting the referring/ordering provider's UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:

• Medicare covered services and items that result from a physician's order or referral;
• Parenteral and enteral nutrition;
• Immunosuppressive drug claims;
• Hepatitis B claims;
• Diagnostic laboratory services;
• Diagnostic radiology services;
• Portable x-ray services;
• Consultative services;
• Durable medical equipment;
• When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);
• When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;
• When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner.

Do not extend the name beyond the confines of this box. Only enter what will fit into item 17. Do not run name into item 17a or 17b.

Tips:

• See Provider Qualifier on left side of Item 17, left of dotted vertical lines
• Leave an appropriate space between data when printing Provider Qualifier and Provider Name in Item 17
• Printing Provider Qualifier to right of dotted vertical line or Provider's Name to left of vertical line could cause inaccurate processing 

Leave Blank. Not required by Medicare.

NPI of the Referring/Ordering Physician
Enter the NPI of the referring, ordering, supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.

Service Furnished as a Result of, or Subsequent to, a Related Hospitalization
Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Additional Claim Information
This is a required field for purposes outlined below.

NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.

• Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date the patient was last seen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physician providing routine foot care submits claims.
• For physical therapy, occupational therapy, and speech-language pathology services, effective for claims with dates of service on or after June 6, 2005, the date last seen and the UPIN/NPI of an ordering/referring/attending/certifying physician or non-physician practitioner are not required. If this information is submitted voluntarily, it must be correct or it will cause rejection or denial of the claim. However, when the therapy service is provided incident to the services of a physician or nonphysician practitioner, then incident to policies continue to apply. For example, for identification of the ordering physician who provided the initial service, see item 17 and (17a-effective May, 23, 200 leave 17a blank) 17b, and for the identification of the supervisor, see item 24J of this section.
• Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the sublaxation). By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of sublaxation) of Pub. 100-02, Medicare Benefits Policy Manual, Chapter 15, is on file, along with the appropriate x-ray and all are available for carrier review.
• Enter the drug's name 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. Otherwise an attachment shall be submitted with the claim. An attachment may 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 "Homebound" when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from Independent Labs, Physicians, and Providers," and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)
• 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.
• Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.
• When dental examinations are billed, enter the specific surgery for which the exam is being performed.
• Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.
• Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share postoperative care.
• Enter demonstration ID number "30" for all national emphysema treatment trial claims.
• Enter the NPI of the physician who is performing a purchased interpretation of a diagnostic test. (See Pub. 100-04, Chapter 1, Section 30.2.9.1 for additional information.)
• Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis (See Pub. 100-04, Chapter 8, Section 60.7.2). Individuals and entities who bill carriers or A/B MACs for administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for Hematocrit tests: TR/R2/27.0.
• If a provider is enrolled in the Competitive Acquisition Program (CAP) for Medicare Part B Drugs and Biologicals, the prescription order number (RX order #) must be reported in item 19 on the CMS-1500 Form.
• For ambulance suppliers, the originating site information will be entered in item 32. It is recommended that providers list both the origin and destination information in item 32. If both the origin and destination do not fit within the confines of item 32, bill the origin in item 32 and the destination information in item 19. List the name of the facility, city, state, and ZIP code. The street address is not required. When transport is beyond the "closest facility", providers are to briefly identify why within the confines of item 19.

Diagnostic and Purchased Tests
Complete this item when billing for diagnostic tests subject to purchase price limitations. 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. When "yes" is annotated, item 32 shall be completed.
• A "no" check indicates "no purchased tests are included on the claim."

When billing for multiple purchased diagnostic tests, each test shall be submitted on a separate claim Form CMS- 1500. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different service facility locations. See chapter 1.

NOTE: This is a required field when billing for diagnostic tests subject to purchase price limitations.

Patient's Diagnosis/Condition

Enter the patient's diagnosis/condition to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.

• The "ICD Indictor" identifies the ICD code set being reported.
  • 0 = ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
• Do not insert a period in the ICD-10-CM code.

Tips:

• ICD Indicator
  • See ICD Indicator in upper right portion of Item 21
  • Must be present and must reflect type of diagnosis submitted in Item 21. Failure to do so will result in claim processing delays.
• Diagnosis Codes
  • Listed from left to right, not top to bottom
  • Do not include decimal points or spaces in diagnosis codes
  • Do not include descriptions or other extraneous information

Leave blank. Not required by Medicare

Prior Authorization Number

• Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
• Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable.
• For physicians performing care plan oversight services, the 6-digit Medicare provider number (or NPI) of the home health agency (HHA) or hospice may be entered when CPT code G0181 (HH) or G0182 (Hospice) is billed; however, CR 4374 allows providers to bill electronic claims without the HHA number.
• Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.
• Enter the ZIP code for the point of pickup for ambulance claims. Because the ZIP code is used for pricing, more than one ambulance service may be reported on the same claim for a beneficiary if all points of pickup are located in the same ZIP code. However, suppliers must prepare a separate claim form for each trip if the points of pickup are located in different ZIP codes. A claim without a ZIP code or with multiple ZIP codes will be denied as unprocessable.

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 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g. N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space-fill the remaining positions (e.g. UN2 or F2999999).

Date of Service
This is a required field. Enter a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date for each procedure, service, or supply within confines of this box. 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.

When billing a date span, it must be for consecutive days. If it is not, then bill each service separately. Days billed should correspond with the number of units in column G. If days span over a month, bill the services for each month on separate lines. Do not use quotation marks to indicate the date of service is the same as the line above. A date must be reported in this item.

Place of Service
This is a required field. Enter the appropriate 2-digit place of service code(s) from the list provided in Section 10.5 of the Medicare Claims Processing Manual, Chapter 26. 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-1500 Form, unless second place of service code is 12 (patient's home).

Leave blank. Not required by Medicare.

Procedures, Services, or Supplies Code
This is a required field. Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 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.

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.

Modifiers must be two alpha/numeric characters. Do not place extra narrative after, under, or above procedure code. Pricing modifiers should be placed in first modifier position. Procedure codes should not be placed in first modifier position. Be sure to distinguish between zeros and 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. Enter the diagnosis code reference letter as shown in Item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference letter per line item. When multiple services are performed, enter the primary reference letter for each service. This will be a letter from A to L.

Tip:

• Multiple characters or numeric characters in Item 24E could delay claim processing

Enter the charge for each listed service
Enter the charge for each listed service. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed.

NOTE: Competitive Acquisition Program (CAP) physicians should enter a billed amount for each CAP drug. Do not enter a zero dollar amount.

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.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures). When multiple services are provided, enter the actual number provided.

For anesthesia, show the elapsed time (minutes) in item 24G. Convert hours into minutes and enter the total minutes required for this procedure (e.g., 2 hours and 10 minutes would be reported as 130. One hour and 10 minutes would be reported as 70).

For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of the Medicate Claims Processing Manual.

Do not place zeros before or after number of units (e.g., a service of 1 should not be billed as 010; it should be billed as 1. Indicate only whole numbers, e.g., do not bill 1.5).

NOTE: This field should contain at least 1 day or unit. The A/B Mac 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.

ID Qualifier
Enter the ID qualifier 1C in the shaded portion when submitting the rendering physician's PIN in 24J. Not required by Medicare as of May 23, 2008.

PIN/NPI of the Rendering Provider
NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.

Enter the rendering provider's NPI number in the lower 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 NPI of the supervisor in the lower unshaded portion. An invalid NPI will cause the claim to be rejected as unprocessable.

Information must be submitted within confines of this box. Do not enter provider names or state postal codes in this item.

Provider or Supplier Federal Tax ID (Employer Identification Number)
Enter the provider of service or supplier Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. 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. Reimbursement of claims submitted without tax identification information will/may be delayed.

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. If an account number is entered in this item, it will appear on the provider remittance notice/advice.

Accept Assignment?
This is a required field, even if you are a participating provider. Check the appropriate block 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.

The following providers of service/suppliers and claims can only be paid on an assignment basis:

• 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.

Total charges for services on claim
Enter total charges for the services (i.e., total of all charges in 24F). Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 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. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 Form should have its own total.

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.

Leave blank. Not required by Medicare.

Signature of Provider of Service or Supplier
This is a required field. Enter the signature of the provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 2008) the form was signed.

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 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. 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 31.

NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature. Noridian is unable to process claims without the required signature and date listed in item 31. 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 and address, and ZIP Code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient's home or physician's office. Effective for claims received on or after April 1, 2004, enter the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and ZIP Code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted. Effective January 1, 2011, for claims processed on or after January 1, 2011, submission of the location where the service was rendered will be required for all POS codes.

Enter name and address information in following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code

NOTE: Enter a complete address for location where the services were performed. A PO Box is not acceptable. Do not include telephone numbers, commas, periods, or other punctuation in address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between city and state postal code. When entering a 9-digit ZIP code, include hyphen.

Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.

For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.

If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than the patient's home.

If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.

Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.

Ambulance suppliers are required to submit both origination and destination information. The originating site information must be entered in Item 32. It is recommended that providers list name of facility, city, state and ZIP code. The street address is not required. If there is not enough space for destination information in Item 32, providers must enter this information in Item 19. The origin and destination modifiers will identify type of facility beneficiary was transported to. When transport is beyond "closest facility", providers are required to briefly identify why and that information is also placed in item 19.

Example:

32. SERVICE FACILITY LOCATION INFORMATION

TO: Hospitals Inc
Anytown IL 60610-6789
FROM: Physician Practice Inc
Anytown IL 60610-1234

NPI of Service Facility
Enter the NPI of the service facility.

Providers of service (namely physicians) shall identify the supplier's NPI when billing for purchased diagnostic tests.

Example:

a. 9876543210

ID Qualifier and PIN
Enter the ID qualifier 1C followed by one blank space and then the PIN of the service facility.

NOTE: Effective May 23, 2008, Item 32b is not to be reported.

Provider's/ Supplier's Telephone Number, Billing Name, Address, and ZIP Code.

This is a required field. Enter the provider of service/supplier's billing name, address, ZIP code, and telephone number.

Enter name and address information in following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code

NOTE: The address should be the provider’s primary clinic or facility location they placed on their enrollment application and assigned to their Provider Transaction Access Number (PTAN). It should not be their biller’s location, mailing address, nor any address not listed in their enrollment.

NPI of Billing Provider or Group
This is a required field. Enter the NPI of the billing provider or group.

Example:

a. 9876543210

NOTE: Effective May 23, 2008, Item 33b is not to be reported.