BlockNo. | Block Name | Block Code | Notes |
24h | EPSDT/Family Planning | A | Enter the 2-digit visit code, if applicable. Visit codes are especially important if providing services that do not require copay (i.e., for a pregnant recipient or long term care resident.) For a complete listing and description of Attachment Type Codes, please refer to the CMS- 1500 Claim Form Desk Reference, located in Appendix A of the handbook. Note: When billing for mileage, it is not necessary to enter a visit code, as the Department does not assess a copayment on mileage charges. |
24i | ID Qualifier | A | Enter the two-digit ID Qualifier: 1D = 13-digit Provider ID Number (legacy #) |
24j (a) | Rendering Provider ID # | A | Complete with the Rendering Provider's Provider ID number (nine-digit provider number and the applicable four-digit service location – 13-digits total). Note: Only one rendering provider per claim form. |
24j (b) | NPI | A | Enter the 10-digit NPI number of the rendering provider. |
25 | Federal Tax I.D. Number | M | Enter the provider’s Federal Tax Employer Identification Number (EIN) or SSN and place an X in the appropriate block. |
26 | Patient’s Account Number | O | Use of this block is strongly recommended. It can contain up to 10 alpha, numeric, or alphanumeric characters and can be used to enter the patient’s account number or name. Information in this block will appear in the first column of the Detail Page in the RA Statement and will help identify claims if an incorrect recipient number is listed. |
27 | Accept Assignment? | LB | Do not complete this block. |
Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.
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- CMS 1500 claim form - How to fill out correctly - Instruction
- Referring provider, Ordering provider and billing provider - CMS 1500 & UB04 form FAQ
- 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, February 6, 2011
Federal tax id number and accept assignment field on CMS 1500
Billing instruction for Ambulance Billing - Box 24h to 27
Labels:
CMS 1500,
CMS 1500 BOX 25,
CMS 1500 BOX 27
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