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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