Wednesday, June 2, 2010




Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: (

For Kidney Disease claims processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

The following fields MUST be completed on the CMS-1500:

Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Kidney Disease Program card.

Block 10d RESERVED FOR LOCAL USE – Enter the 6 digit Kidney Disease Program Patient Identification Number. If this field is left blank, the claim will be returned as invalid.

Block 21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY – Enter the 3, 4, or 5 character code from the ICD-9 related to the procedures, services, or supplies listed in Block #24d. List the primary diagnosis on Line 1 and secondary diagnosis on Line 2. Additional diagnoses are
optional and may be listed on Lines 3 and 4.

Block 24A DATE(S) OF SERVICE – Enter each separate date of service as a 6-digit numeric date (e.g. June 1, 2005 would be 06/01/05) under the FROM heading. Leave the space under the TO heading blank. Each date of service on which a service was rendered must be listed on a separate line. Ranges of dates are not accepted on this form.

Block 24B PLACE OF SERVICE – For each date of service, enter the appropriate 2- digit place of service code to describe the site.

Block 24C EMG – Leave Blank.

Block 24D PROCEDURES, SERVICES OR SUPPLIES – Enter the five-character procedure code that describes the service provided and two-character modifier, if required.

Block 24E DIAGNOSIS POINTER – Enter appropriate information.

Block 24F CHARGES – Enter the usual and customary charges. Do not enter the Maryland Medicaid maximum fee unless that is your usual and customary charge. If there is more then one unit of service on a line, the charge for that line should be the total of all units.

Block 24G DAYS OR UNITS – Enter appropriate days or units.

Block 24H EPSDT FAMILY PLAN – Leave Blank.

Block 24I ID. QUAL. – Leave Blank

Block 24J RENDERING PROVIDER ID. # – Leave Blank

Block 25 FEDERAL TAX I.D. NUMBER – Enter your Federal Tax ID number. In addition, enter your store number if one has been assigned to your store.

Block 28 TOTAL CHARGE – Enter the sum of the charges shown on all lines of Block #24F of the invoice.

Block 29 AMOUNT PAID – Enter the amount of any collections received from any third party payer, except Medicare.

Block 30 BALANCE DUE – Enter coinsurance and/or deductible amounts due, if Medicare eligible. Enter total charges due, if not Medicare eligible. If other third party payment is made, enter coinsurance and/or deductible amounts due.

Block 33 BILLING PROVIDER INFO & PH# - Enter the name, complete street address, city, state, and zip code of the provider. This should be the address to which claims may be returned.

Block 33a
NPI - Enter the NPI number of the billing provider in Block # 33. Errors or omissions of this number will result in non-payment of claims.

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