CMS-1500 form 2023 with complete solution

(ASCA) The Administrative simplification compliance act requires that claims to medicare be transmitted electronically, unless clearinghouse is being used by a provider to submit claims a draft may be completed on paper (ASCA) The Administrative simplification compliance act (NUCC) National Uniform Claim Committee (NUCC) National Uniform Claim Committee Organization that maintains the CMS-1500 form any new version would have to be approved by the White House Office Management and Budget(OMB) (OMB) White House Office Management and Budget Blocks 1-13 focus on basic information about the patient, and the insured (if diff) also determining which plan is primary and secondary if patient has more than 1 insurance(block 11) Block 1 Check the box indicating what kind of insurance Block 1a Patient's Medicare Health insurance claim number (HICN), such as MEDICARE, MEDCAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA BLK LUNG this number is required whether medicare is primary or secondary Block 2 the patients' first name, middle initial, and last name as shown on the patient's Medical card Block 3 Patient's eight digit birth date recorded as MM/DD/CCYY and sex ie: April 04, 1995 would be 04/04/1995 Block 4 If there is insurance primary to medicare, obtained through the patient's or spouse's place of work or through any other source, list the name of the insured here. if the patient and the insured are the same, write SAME. If medicare is primary, leave this field blank. Block 5 Patient's mailing address and telephone number. mailing address on first line, the city and state on second line, and the zip code and telephone number on the third line. Block 6 Check the appropriate box for the patient's relationship to the insured, self, spouse, child, other Block 7 Enter the insured's address and telephone number . If the insured is the same as the patient write, SAME. complete this block only after 4, 6, and 11 have been completed. Block 8 Leave Blank Block 9 Write the last name , first name and middle initial of the medicap enrollee if it is a differnt person from the one listed in block 2. Otherwise, write SAME. If no medigap benefits are assigned, leave blank. Block 9A Enter the policy and/or group number of the medigap insures preceded by MEDIGAP, MG, or MGAP. Block 9B Leave blank Block 9C Leave blank if block 9d is filled out. Otherwise, enter the claims processing address of the medicap insurer. Use an abbreviated street address, two letter postal code, and zip code from the Medigap insured's identification card. For example 1234 Park ave, New York, New York 20072 should be written as 1234 Park ave. NY 20072. Block 9D Write in the coordination of benefits Agreement Medigap-based identifier. Blocks 10A-10C Check YES or NO to indicate whether employment, auto liablity, or other accidents involvement applies to one or more of the services listed in block 24. A YES answer indicates there may be other insurance primary to Medicare. Block 11 This is an important field. This is the place to indicate that a good faith effort has been made to determine whether Medicare is the primary insurance. Information about insurance primary to Medicare should be listed in Block 11A-11C. Instances where Medicare is the secondary insurance include the following; *Group health plan coverage ; -working aged, -Disability(large group health plan) -End-stage renal disease *No-Fault or other Liability *Work-related illness/ injury -workers' compensation -Black Lung -Veterans benefits Block 11A This is where the insured's birth date goes. Enter the Sex as well if it is different from block 3. Block 11B Enter the employer's name and any change in insurance status. Block 11C Enter the nine-digit payer ID number of the primary insurer. If there is no payer ID, then write in the primary payers's program or plan name. If the explanation of benefits (EOB) does not include the claim's processing address, then write it in. Block 11D Leave Blank Block 12 This is an important field. This is the place where the patient or an authorized person signs to authorize the release of medical information. The field must be dated and entered as a six- or eight-digit date. A signature can also be used. The patients' signature authorizes release of information necessary to process the claim. Block 13 This Signature authorizes payment of benefits to the provider or supplier. A signature on file is acceptable here. Why is block 11 important? this is the place to indicate that a good faith effort has been made to determine which is the primary insurance and which is secondary. Block 14 -33 (POS) Provider of service or Supplier information. These fields include information about the providers, services rendered, diagnoses made, procedures performed, and modifiers needs. Block 14 Either a six-digit or eight-digit date of current illness, injury, or pregnancy: MMDDYY() or MMDDCCYY(). IMPORTANt: The two styles of numbers cannot be used in one claim. Use one or the other consistently throughout Block 15 Leave blank Block 16 Dates patient is unable to work in his/her current occupation. This is required if the patient is eligible for disability or workers' compensation benefits. To fill out this field, enter FROM and TO dates as follows: MMDDYY or MMDDCCYY Block 17 This is the name of the referring or ordering provider goes. If medicare requires that a supervising provider be listed, this is where to put the name. If a claim involves more than one referring, ordering, or supervising provider, a separate claim must be submitted for each one. Qualifiers for different kinds of providers DN- Referring provider- The physician who requests the service for the patient. DK- Ordering Provider- A physician or when appropriate, a non-physician who orders non-physician services for the patient. These services include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment. DQ- Supervisor provider- The physician monitoring the patients care. Block 17A Leave Blank Block 17B The NPI# goes here. As part of the enrollment process, all providers must apply for an NPI number. Authorized under the HIPAA Simplification Rule, the NPI is a unique identification number for all HIPAA-covered entities, including individuals, organizations, home health agencies, clinics, nursing homes, residential treatment homes, laboratories, ambulances, group practices, and health maintenance organizations (HMO). Block 18 dates entered when a medical service rendered is a result of or subsequent to, a related hospitalization. Block 19 Dates entered for when the patient was last seen and the NPI of the attending provider when a provider providing routine foot care submits a claim. Other blocks that could be listed in this field include the following: -The name and dosage of drugs listed as not otherwise classified (NOC) -HOMEBOUND to indicate that laboratory specimens were taken from a patient confined to his/her home or an institution -PATIENT REFUSES TO SIGN BENEFITS, when a beneficiary refuses to assign benefits to a non-participating provider or supplier -TESTING FOR HEARING AID when billing services are involved in this testing. Block 20 Mark YES to the question asked if lab test were done by an entity other than the one doing the billing. If multiple tests are involved, each should be filed under a separate claim. Block 21 This is where the diagnosis codes go. Block 22 Leave Blank Block 23 The quality improvement organization (QIO) prior authorization number goes here for those procedures that require it. Enter the investigational device exemption (IDE) when an investigation device is used in an FDA-approved clinical trial. Block 24A Dates of services are listed here FROM-TO. Blocks can include no more than two dates of service for the same procedure code. When FROM and TO dates are shown for a series of identical services, list them as a series of days in column G. Block 24B This is where places of services codes go. These must be HIPAA-compliant. Codes are shown as two digit numbers. For example: 01 should be used for a pharmacy, 02 is an unassigned number, 03 is for a school, and 04 is for a homeless shelter. ect... Block 24C Medicare providers do not have to fill out this field Block 24D Enter procedures, services, and supplies. For this field , use CPT or CHPCS codes. This is also the place where MODIFIERS go. MODIFIERS are additional information about types of services, such as surgical care, or outpatient services. Modifiers are part of valid CPT or HCPCS codes. Block 24E is for the diagnosis refernce code, as shown in Block 21. This field matches the date of service to the procedured performed under the primary diagnosis code. Enter only one reference number per line. Do NOT enter diagnosis code here. Block 24F Enter the providers billed charges for each service Block 24G Enter the days or units. This field is mostly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If onlyone service is performed, the number 1 must be entered. Block 24H Leave Blank Block 24I Enter the ID qualifier 1C in the shaded portion. Block 24J Enter the providers NPI in the unshaded portion Block 25 Enter the provider's or supplier's federal ID number or social security number and check the appropriate box. Block 26 Enter total charges for all services. Block 27 Check the appropriate box to indicate whether the provider or supplier accepts assignment of medicare benefits. Be aware of which providers can only be paid on an assignment basis. Block 28 Enter toatl charges for all services Block 29 Enter the total amount the patient paid for covered services only. Block 30 Leave Blank Block 31 Enter the signature of the provider or the signature Block 32 Enter the name, address, and ZIP code of the facility where services were rendered. POS codes are needed here as well. Block 32A If required by the Medicare claims processing policy, enter the NPI of the facility. Block 33 The provider's or supplier's billing name, address ZIP code, and telephone number. Block33A The NPI of the billing provider Healthcare Common procedure Coding System.(HCPCS) A group of codes and descriptors used to represent health care procedures, supplies, and products, and services.