Prior Authorization Number
This is a required field for the purposes outlined below.
• Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
• Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable.
• Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.
• Enter the ZIP code for the point of pickup for ambulance claims. Because the ZIP code is used for pricing, more than one ambulance service may be reported on the same claim for a beneficiary if all
points of pickup are located in the same ZIP code. However, suppliers must prepare a separate claim form for each trip if the points of pickup are located in different ZIP codes. A claim without a ZIP code or with multiple ZIP codes will be denied as unprocessable.
NOTE: Item 23 can contain only one condition. Any additional conditions should be reported on a separate CMS–1500 Form.
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Tuesday, November 2, 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