Sunday, April 17, 2011

CMS 1500 - Data requirements - quick review

Data Requirements
Providers must either submit a CMS-1500 (or equivalent) or UB-04 paper claim form with all the
information that is required for original Medicare submission or file the required data electronically. Failure
to complete all required information could result in the claim rejecting, payment delays, and/or additional
development requests. Following are data requirements:

CMS-1500:
• Patient’s name (block 2)
• Insured’s name (block 4)
• Member ID number (block 1a)
• Patient relationship to member (block 6)
• Patient date of birth (block 3)
• Date of service (block 24A)
• CPT procedure codes with modifiers
when appropriate (block 24D)
• ICD diagnosis code(s) to highest level
of specificity (block 21)
• Place of service (block 24B)
• Unit(s) of service (block 24G)
• Charge(s) (block 24F)
• Performing provider's individual number or professional association (PA) NPI, if applicable (block 24J)
• Federal Tax ID number (block 25)
• Provider of service signature (block 31)
• Billing provider’s information and phone (block 33)
• Billing provider’s NPI, if applicable (block 33a)
• Billing provider’s other ID number (i.e., BCBSF provider number), if applicable (block 33b)

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