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
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
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Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), al...
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifie...
For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
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...
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...
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...
Click the image for see full size sample CMS 1500 claim form. Claim Form Sample