Tuesday, November 30, 2010

Box 17 - 19 - Reserved for local use - cms 1500

Billing instruction for Ambulance Billing - Box 17 to 19



BlockNo. Block Name Block Code Notes
17 Name of Referring Physician or Other Source M Enter the name and the degree of the attending practitioner.
17a I.D. Number of Referring Physician A In the first portion of this block, enter a two-digit qualifier that indicates the type of ID:
0B = License Number
1D = 13-digit Provider ID number (Legacy
Number)
In the second portion, enter the
license number of the referring or prescribing practitioner named in Block 17 (e.g., MD123456X). If the practitioner's license number was issued after June 29, 2001, enter the number in the new format (e.g., MD123456).
If an out-of-state provider orders the service, enter the two-letter State abbreviation, followed by six
9’s, and an X. For example, a prescribing practitioner from New Jersey would be entered as NJ999999X.
17b NPI # A Enter the 10-digit National Provider Identifier number of the referring provider, ordering provider, or other source.
18 Hospitalization Dates Related to Current Services LB Do not complete this block.
19 Reserved For
Local Use
A/A This field must be completed with attachment type codes, when applicable. Attachment type codes begin with the letters “AT”, followed by a two- digit number (i.e., AT05).
Enter up to four, 4-character alphanumeric attachment type codes. When entering more than one attachment type code, separate the codes with a comma (,).

Friday, November 26, 2010

Billing instuction box 11D - 16 - Is there another health benefit plan

Billing instruction for Ambulance Billing - Box 11d to 16



BlockNo. Block Name Block Code Notes
11d Is There Another Health Benefit Plan? A If the patient has another resource available to pay for the service, bill the other resource before billing MA. If the YES box is checked, Blocks 9a–d must be completed with the information on the
additional resource.
12 Patient’s or Authorized Person’s Signature and Date M/M The recipient’s signature or the words Signature
Exception must appear in this field.
Also, enter the date of claim submission in an 8- digit MMDDCCYY format (e.g., 03012004) with no slashes, hyphens, or dashes.)
Note: Please refer to Section 6 of the PA PROMISeProvider Handbook for the 837
Professional/CMS-1500 Claim Form for additional information on obtaining patients signatures.
13 Insured’s or Authorized Person’s Signature O If completed, this block should contain the signature of the insured, if the insured is not the patient.
14 Date of Current: O If completed, enter the date of the current illness (first symptom), injury (accident date), or pregnancy in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012004).
15 If Patient Has Had Same or Similar Illness O If the patient has had the same or similar illness, list the date of the first onset of the illness in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012002).
16 Dates Patient Unable to Work in Current Occupation O If completed, enter the FROM and TO dates in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012003), only if the patient is unable to work due to the current illness or injury.
This block is only necessary for Worker’s Compensation cases. It must be left blank for all other situations.

Thursday, November 25, 2010

Tuesday, November 23, 2010

BOX 9C to 11C - Is patient condition related to field of CMS 1500

Billing instruction for Ambulance Billing - Box 9C to 11C





BlockNo. Block Name Block Code Notes
9c Employer’s Name or School Name A Enter the name of the other insured’s employer.
9d Insurance Plan Name or Group Name A Enter the other insured’s insurance plan name or group name.
10a-10c Is Patient’s Condition Related To: A Complete the block by placing an X in the appropriate YES or NO box to indicate whether the patient’s condition is related to employment, auto accident, or other accident (e.g., liability suit) as it applies to one or more of the services described in Block 24d. For auto accidents, enter
the state’s 2-digit postal code for the state in which the accident occurred in the PLACE block (e.g.,
PA for Pennsylvania).
10d Reserved For
Local Use
O It is optional to enter the 9-digit social security number of the policyholder if the policyholder is not the recipient.
11 Insured’s Policy Group or FECA Number A/A Enter the policy number and group number of the primary insurance other than MA.
11a Insured’s Date of
Birth and Sex
A/A Enter the insured’s date of birth in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and insured’s gender if it is different than Block 3.
11b Employer’s Name or School Name A Enter the name of the other insured’s employer for the primary insurance.
11c Insurance Plan Name or Program Name A List the name and address of the primary insurance listed in Block 11.

Thursday, November 18, 2010

box number 1 - 4 - How to fill and instruction - upperright hand portion important

CMS-1500 Claim Form Completion for Ambulance Providers

You must follow these instructions to complete the CMS-1500 claim when billing the Department of Public Welfare. Do not imprint, type, or write any information on the upperright hand portion of the form. This area is used to stamp the Internal Control Number (ICN),which is vital to the processing of your claim. Do not submit a photocopy of your claim to Medical Assistance.


BlockNo. Block Name Block Code Notes
1 Type of Claim M Place an X in the Medicaid box.
1a Insured’s ID Number M Enter the 10-digit recipient number found on the ACCESS card. If the recipient number is not available, access the Eligibility Verification System (EVS) by using the recipient’s Social Security Number (SSN) and date of birth (DOB). The EVS response will then provide the 10-digit recipient number to use for this block.
2 Patient’s Name A It is recommended that this field be completed to enable Medical Assistance (MA) to research questions regarding a claim.
*This field is required when billing for newborns using the mother’s recipient number. Enter the newborn’s name. If the first name is not available, you are permitted to use Baby Boy or Baby Girl.
3 Patient’s Birthdate and Sex A Enter the patient’s date of birth using an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 02151978) and indicate the patient’s gender by placing an X in the appropriate box.
*Same as the special instruction for Block 2. Enter the newborn’s date of birth in an eight-digit format.
4 Insured’s Name A If the patient has health insurance other than MA, list the name of the insured here. Enter the name of the insured except when the insured and the patient are the same - then the word SAME may be entered. If there is no other insurance other than MA, leave this block blank.

Wednesday, November 17, 2010

how to fill ambulance claim - CMS 1500 - BOX 5 - BOX 9B

Billing instruction for Ambulance Billing

 
BlockNo. Block Name Block Code Notes
5 Patient’s Address O Enter the patient’s address.
6 Patient’s Relationship to the Insured A Check the appropriate box for the patient’s relationship to the insured listed in Block 4.
7 Insured’s
Address
A Enter the insured’s address and telephone number except when the address is the same as the patient’s, then enter the word SAME. Complete this block only when Block 4 is completed.
8 Patient Status O Place an X in the appropriate blocks to describe the patient’s status.
9 Other Insured’s
Name
A If the patient has another health insurance secondary to the insurance named in Block 11, enter the last name, first name, and middle initial of the insured if it is different from the patient
named in Block 2. If the patient and the insured are the same, enter the word SAME. If the patient has MA coverage only, leave the block blank.
9a Other Insured’s Policy and Group Number A This block identifies a secondary insurance other than MA, and the primary insurance listed in 11a- d. Enter the policy number and the group number of any secondary insurance that is available. Only use Blocks 9a-d, if you have completed Blocks
11a-d, and a secondary policy is available. (For example, the patient may have both Blue Cross and Aetna benefits available.)
9b Other Insured’s Date of Birth and Sex A If a secondary insurance exists, enter the other insured’s date of birth. Please make sure the date is in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and indicate the patient’s gender by placing an X in the appropriate box.

Tuesday, November 16, 2010

CMS 1500 - 24j and 33a NPI different option of individual NPI and group NPI

Effective May 23, 2008

Only an NPI may be entered in any provider identifier fields on claims submitted on or after May 23, 2008. Claims will be rejected when submitted with a Medicare legacy number (PIN/PTAN) or a UPIN in any provider identifying field on or after May 23, 2008.

Type 1 is an individual NPI. Type 2 is an organizational NPI.
Incorporated Individual with individual legacy number and individual NPI:

24J – Enter nothing
33a – Enter type 1 Individual NPI

Incorporated Individual with individual legacy, group legacy, individual NPI and group NPI:

24J – Enter type 1 Individual NPI
33a – Enter type 2 Corporation NPI

Sole Proprietor, not billing for an employee:
24J – Enter nothing
33a – Enter type 1 Individual NPI

Sole Proprietor, billing for an employee:
24J – Enter type 1 Employee individual NPI
33a – Enter type 1 Individual NPI in

Clinics and multiple group offices:
24J – Enter type 1 Individual NPI
33a – Enter type 2 Group NPI

Organizations/Facilities (e.g. ASC, Ambulance, IDTF, etc.):
24J – Enter nothing
33a – Enter type 2 Facility NPI

Provider set up as a group (individual and group legacy) and only one NPI: Contact Provider Enrollment: (888) 608-8816 [Select Option 1]

Monday, November 15, 2010

CMS-1500 CLAIM FORM COMPLETION - AMBULANCE BILLING with example

CMS-1500 Claim Form Completion for Ambulance Providers

IMPORTANT INFORMATION FOR CMS-1500 CLAIM FORM COMPLETION

Note #1: If you are submitting handwritten claimforms you must use blue or black ink.
Note #2: Font Sizes— Because of limited field size, either of the following type faces and sizes are recommended for form completion:
• Times New Roman, 10point
• Arial, 10 Point
Other fonts may be used, but ensure that all data will fit into the fields, or the claim may not process correctly.

Note #3: When completing the following blocks of the CMS-1500,do not use decimal points and be sure to enter dollars and cents:
1 .Block 24F ($Charges)
2. Block 29 (Amount Paid)
If you fail to enter both dollars and cents, your claim may process incorrectly. Forexample, if your usual charge is sixty-five dollars and you enter 65, your usual chargemay be read as .65 cents.

Example #1:

When completing Block 24F, enter your usual charge to the general public, without a decimal point. You must include the dollars and cents. If your usual charge is two hundred and fifty dollars, enter:
24F
$CHARGES
250.00

Example #2:
When completing Block 29, you are reporting patient pay assigned by the CountyAssistance Office (CAO). Enter patient payas follows, including dollars and cents:
29
Amount Paid
50.00

Tuesday, November 2, 2010

when to use authorization or CLIA or zip code on box 23 - cms 1500

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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