When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) assigned to the paid claim. This ICN appears on the remittance advice on which the original claim was paid. Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction.
When resubmitting a denied claim, enter an “R” followed by the 13-character ICN assigned to the denied claim. This ICN appears on the remittance advice on which the original claim was denied.
Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction.
Situational. If filing an adjustment or
void, enter an “A” for an adjustment
or a “V” for a void as appropriate
AND one of the appropriate reason
codes for the adjustment or void in
the “Code” portion of this field.
Enter the internal control number
from the paid claim line as it appears
on the remittance advice in the
“Original Ref. No.” portion of this
Appropriate reason codes follow:
01 = Third Party Liability Recovery
02 = Provider Correction
03 = Fiscal Agent Error
90 = State Office Use Only – Recovery
99 = Other
10 = Claim Paid for Wrong Recipient
11 = Claim Paid for Wrong Provider
00 = Other
- COMPLETION OF CMS-1500 - Full field instruction
- Referring provider, Ordering provider and billing ...
- 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
Sunday, October 3, 2010
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