Wednesday, May 26, 2010

Box 17 - 23 - How to file the claim - CMS 1500

Middle section of CMS 1500 form

Box 17a - Optional

Referring Provider Number

�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).

Box 17b - Optional

Referral National Provider Identifier (NPI)

�� If information was entered in box 17a (Primary Care Manager, or other referral) the corresponding NPI is entered here.
�� Enter the ten-digit NPI of the referring provider.

Box 21 - Required

Diagnosis Code
�� Enter the client’s diagnosis/condition.
�� The diagnosis code must be the reason chiefly responsible for the service being provided as
shown in medical records.
�� You may enter up to four codes and they must be carried out to its highest degree of specificity.
�� Do not use the decimal point.

Note: Diagnosis codes are not required for transportation providers.

Box 23 - Optional

Prior Authorization Number
�� If the service you provided requires prior authorization (PA), enter the ten-digit prior authorization number that was issued for the service.
�� Only use one prior authorization number per claim form.
�� Do not bill prior authorized and non-authorized services on the same claim form.

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