Wednesday, December 16, 2015

BOX 31 to BOX 33 - Detailed review

31 Signature Signature of person authorized to certify this claim. By signing the BMS Provider Enrollment Agreement providers have certified that all information listed on a claim for reimbursement from Medicaid is true, accurate and complete. Therefore, claims may be endorsed with a computer-generated, manual or stamped signature.

date Enter the claim submission date.


32 Service Facility Location Information
Enter name and address of rendering site, if patient was seen in institutional setting. (Hospital, Nursing Home, etc.)

32 A&B Servicing Facility NPI
A. Enter in the Servicing Facilities NPI
B. Non applicable


33 Billing Provider Info and Phone number
Enter required information as followed: Phone Name Address City, State & 9 digit zip code


33A NPI number of Physician or Supplier 
Enter the NPI of the servicing or rendering provider or group or pay-to. If the servicing /rendering is in 24j then enter in the servicing providers group number.

33B Taxonomy code of Physician or Supplier
Enter ZZ (qualifier) if you are entering in a taxonomy code for the pay-to No spaces between qualifier and value.

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