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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...
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For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
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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...
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Bottom section of the CMS 1500 form Supplemental information Shaded line �� In the shaded area across Fields 24A through 24H, enter s...
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TWO-DIGIT QUALIFIERS The shaded fields in boxes 17a, 24I, 24J, 32b and 33b should be used to report provider numbers other than the NPI as...
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Click the image for see full size sample CMS 1500 claim form. Claim Form Sample -
“CLIA” - The Clinical Laboratory Improvement Act and CMS implementing regulations and processes. A paper claim for laboratory testing ...
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The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery dis...
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