If services were in a location other than the Provider’s office or the member’s home, enter the name and address of that facility.
32 a. Enter the Facility NPI number. Not required at this time.
32 b. Enter the 2-digit MaineCare Identifier (1D) and one space followed by the Facility Provider number. Do not enter the Servicing Provider ID number here. Not required at this time.
Item 32 Form CMS-1500 (12-90) - 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.
Providers of service (namely physicians) shall identify the supplier's name, address, ZIP
Code and PIN when billing for purchased diagnostic tests. When more than one supplier
is used, a separate Form CMS-1500 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, address, or PIN 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 Form CMS-1500
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 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, and the
PIN.
Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.
Pages
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- CMS 1500 claim form - How to fill out correctly - Instruction
- Referring provider, Ordering provider and billing provider - CMS 1500 & UB04 form FAQ
- Medicare provider Enrollment question and answer part 1
- Medicare Enrollment - question and answer part 2
- Complete claim submission - some tips
- Medicare Deductible FAQ
- Secondary claim submission CMS 1500 requirements
- UB 04 - Complete instruction to fill the form
Friday, June 25, 2010
CMS 1500 - BOX 32: SERVICE FACILITILY LOCATION INFORMATION
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Billing instruction,
cms 1500 box 32
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