For each line item billed, you must include one date, one place of service, one procedure code, and one amount charged per line. For a paper claim, you may not bill more than six lines.
BOX 24A: DATE(S) OF SERVICE
Enter both “From” and “To” dates of service using either six-digit (MMDDYY) or eight-digit (MMDDYYYY) format. Do not use commas, dashes, or slashes in the date.
Dates must be consecutive and continuous. If the service was provided on only one day, just put that date in the From field. On each line, the From and To dates must be during one month. Use the next line for the next month.
BOX 24B: PLACE OF SERVICE
Enter a two-digit Place of Service code
BOX 24C: EMG
Enter a Y to prevent copay from being deducted if you are not billing services that are exempt from copay
BOX 24D: PROCEDURES, SERVICES OR SUPPLIES
Enter the appropriate procedure code and modifier(s), if necessary in the unshaded area..
NOTE: The shaded area at the top of this box is to be used for supplemental information
BOX 24E: DIAGNOSIS POINTER
From Box 21, enter the line number or numbers (1, 2, 3, and/or 4) that list the diagnosis codes. Do not enter the codes themselves. List only the line numbers.
BOX 24F: $ CHARGES
Enter the usual charge for the service you provided based on the policy section under which you are billing.
BOX 24G: DAYS OR UNITS
Enter the number of days of service or the units of supplies provided. Do not use decimal points or fractions. Round off to the nearest whole number. Enter 1 only if 1 unit was provided. (For example: For Indian Health Centers or Rural Health Centers, 1 unit of a visit is 1, not the units of itemized
services provided in that visit.)
24I: ID QUALIFIER
You must enter the appropriate qualifier in the shaded area of this box 1D indicates MaineCare Servicing Provider Number should be in Box J.
24J: RENDERING PROVIDER ID NUMBER
Enter the Servicing Provider ID number in the shaded area, if applicable. Enter the Servicing Provider NPI number in the area that is not shaded. MaineCare does not require an NPI at this time.
If a Servicing Provider ID number is not required, leave this field empty.
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The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifie...
Item 17 Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicia...
Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), al...
For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
Bottom section of the CMS 1500 form Supplemental information Shaded line �� In the shaded area across Fields 24A through 24H, enter s...
Billing instruction for Ambulance Billing - Box 20 to 23 BlockNo. Block Name Block Code Notes ...
When submitting attachments with the CMS-1500 claim form, please follow these guidelines: Any attachment should be marked with the benef...
Click the image for see full size sample CMS 1500 claim form. Claim Form Sample
The fields on the UB claim form are called Field Locators (FL). Shaded boxes are fields DMAP uses to process your claim; your claim may susp...