CMS MEDICARE MANUALS
- 9.1 Overview
- 9.2 Ordering CMS-1500 (12-90) and (08-05) Claim Forms
- 9.3 Completion of the CMS-1500 (08-05) Claim Forms
- 9.4 Join CMS in Saving Medicare Trust Funds
- 9.5 Mandatory Claim Submission
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ALL PAPER CLAIMS YOU SUBMIT ON BEHALF OF YOUR MEDICARE PATIENTS MUST BE SUBMITTED USING THE CMS-1500 (08-05) CLAIM FORM. The CMS-1500 (08-05) claim form is furnished to you printed in red ink. This is the only format that is accepted. Photocopies or xerox copies of the form will not be processed.
Note: Please reference our March 13, 2007 "What’s New" article pertaining to additional information regarding the use of the CMS-1500 (12-90) and (08-05) claim form. You can visit our website at: http://www.highmarkmedicareservices.com/partb/whatsnew/2007.html. For your convenience, we have kept both formats for items 24, 32 and 33 on the CMS-1500 (12-90) and (08-05) claim forms.
Medicare will not accept non-standard claims. Non-standard claims (i.e. "Superbills") can be defined as claims with extraneous attachments that are submitted by providers of service and (or) suppliers in lieu of entering the required information in the designated blocks on the CMS-1500 (08-05) claim form. Claim attachments will be accepted only for information and evidence that cannot be readily entered in designated blocks of the standard claim form (i.e. medical records, certificates of medical necessity, other certifications or claim attachments required by law, regulations, or CMS instructions).
The conditions which constitute a complete, valid claim have been standardized. Please refer to Section 9.3, Completion of the CMS-1500 (08-05) claim form, for instructions on completing your Medicare Part B claims. All blocks on the claim form must be completed unless otherwise noted. These are defined as "required" or "mandatory." Those blocks noted as "conditional" must be completed for specific situations as noted within the block description. Any claim which is considered incomplete or invalid, due to missing CMS-1500 (08-05) claim form data elements, will be returned for ICR references as "unprocessable".
9.2 Ordering CMS-1500 (12-90) and (08-05) Claim Forms
The form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS-1500 (08-05) claim forms may be purchased from local printers or through the following organizations:
U. S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
(202) 512-1800 (Pricing Desk)
FAX# (202) 512-2250
or
Order Department
AMA
P.O. Box 109050
Chicago, IL 60610-9050
American Express, Visa and Master Card orders may be placed by calling 1-800-621-83359.3 Completion of the CMS-1500 (08-05) Claim Forms
Completing the CMS-1500 (08-05) Claim Forms
The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims. The top right margin of the claim form should NOT contain:
- any type of adhesive-backed label
- printing or headings (including the Medicare carrier address)
- ink, markers, whiteout, etc.
Please print legibly or type all information. Claims may also be computer-prepared.
ITEM 1Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Completion of this item is required for all claims.
ITEM 1a INSURED'S I.D. NUMBER (For Program in Block 1)
Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
Completion of this item is required for all claims.
ITEM 2 PATIENT'S NAME
Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.
Completion of this item is required for all claims.
ITEM 3 PATIENT'S BIRTH DATE AND SEX
Enter the patient's birth date (MMDDCCYY) and sex.
Completion of this item is required for all claims.
ITEM 4 INSURED'S NAME
If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word "SAME". If there is no insurance primary to Medicare, leave blank.
Completion of this item is conditional for insurance information.
ITEM 5 PATIENT'S ADDRESS
Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000. Reminder, please report the address where the home visit occurred rather than the beneficiary's address if they are out of the area.
Completion of this item is required for all claims; address and telephone must be indicated.
ITEM 6 PATIENT RELATIONSHIP TO INSURED
Check the appropriate box for patient's relationship to the insured when item 4 is completed.
Completion of this item is conditional for insurance information when item 4 is completed.
ITEM 7 INSURED'S ADDRESS
Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4 and 11 are completed.
Completion of this item is conditional for insurance information when items 4, 6 and 11 are completed.
ITEM 8 PATIENT STATUS
Check the appropriate box for the patient's marital status and whether employed or a student.
ITEM 9 OTHER INSURED’S NAME
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.
Note: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier.
Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer.
Medigap – A Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in 1882(g)(1) of Title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation which is incorporated by reference in the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the application of deductibles, coinsurance amounts or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.
Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.
ITEM 9a OTHER INSURED’S POLICY OR GROUP NUMBER
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.
Note: Item 9d must be completed, even when the provider enters a policy and/or group number is in item 9a.
ITEM 9b OTHER INSURED’S DATE OF BIRTH
Enter the Medigap enrollee’s birth date (MMDDCCYY) and sex.
ITEM 9c EMPLOYER’S NAME OR SCHOOL NAME
Leave blank if a Medigap PAYERID is entered in item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured’s Medigap identification card. For example:
1257 Anywhere Street
Baltimore, MD 21204is shown as "1257 Anywhere St MD 21204."
ITEM 9d INSURANCE PLAN NAME OR PROGRAM NAME
Enter the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.
If the beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d. A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary’s claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See chapter 28 §70.6.4 for more information concerning the COBA Medigap claim-based crossover process.)
ITEM 10a THROUGH 10c IS PATIENT'S CONDITION RELATED TO:
Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the state postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.
Completion of items 10a-c are required for all claims; "Yes" or "No" must be indicated.
ITEM 10d RESERVED FOR LOCAL USE
Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by "MCD".
ITEM 11 INSURED'S POLICY, GROUP OR FECA NUMBER
When submitting paper or electronic claims, item 11 must be completed. By completing this information, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Claim without this information will be returned for ICR references.
Note: If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a-11c.
If there is no insurance primary to Medicare, enter the word "NONE" in item 11 and proceed to item 12.
If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to item 11b.
If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word "None" in item 11 of the CMS-1500, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.
Completion of item 11 (i.e., insured's policy/group number or "NONE") is required on all claims.
Completion of items 11b-c are conditional for insurance information primary to Medicare.
Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to another insurance include:
- Group Health Plan Coverage:
- Working Aged;
- Disability (Large Group Health Plan); and
- End Stage Renal Disease.
- No Fault and/or other Liability;
- Work-Related Illness/Injury:
- Workers' Compensation;
- Black Lung; and
- Veterans Benefits.
Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Pub. 100-5, Medicare Secondary Payer Manual, Chapter 3).
ITEM 11a INSURED'S DATE OF BIRTH
Enter the insured's birth date (MMDDCCYY) and sex, if different from item 3.
ITEM 11b EMPLOYER'S NAME OR SCHOOL NAME
Enter the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter the six - digit retirement date (MMDDYY) preceded by the word "RETIRED."
Completion of this item is conditional when the beneficiary has insurance primary to Medicare.
ITEM 11c INSURANCE PLAN NAME OR PROGRAM NAME
Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB.
Completion of this item is conditional for insurance information primary to Medicare.
ITEM 11d IS THERE ANOTHER HEALTH BENEFIT PLAN
Leave blank. Not required by Medicare.
ITEM 12 PATIENT OR AUTHORIZED PERSON'S SIGNATURE
The patient or an authorized representative must sign and enter the six-digit date (MMDDYY) for this item unless the patient is deceased, you do not have direct contact with the patient (laboratory), or the signature is on file. Please use SIGNATURE EXCEPTION in item 12 for situtations where the patient is deceased or you do not have direct contact. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by: "by" the representative’s name, address, relationship to the patient, and the reason the patient cannot sign the form. The signature on file authorization is effective indefinitely unless the patient or the patient’s representative revokes the arrangement.
The patient's signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.
All claims must have item 12 completed. Failure to include an appropriate signature and six-digit date or a "signature on file" statement will result in a claim rejection. A Medigap authorization signature in item 13 does not satisfy the Block 12 signature requirement.
Signature By Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.
Signature on File
Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary's behalf.To utilize this procedure, the patient must sign and date a brief statement as follows:
Once the provider of service and (or) supplier has obtained the patient's one-time authorization, any later Medicare claims may be submitted by the provider of service and (or) supplier without obtaining any additional signature and date from the patient. When submitting claims, the statement "Signature on file" must be reflected in the patient's signature space (item 12) of the Health Insurance Claim Form.(Name of Beneficiary) (Health Insurance Claim Number)
"I request that payment of authorized Medicare benefits be made either to me
or on my behalf to the name of provider of service and (or) supplier for any
services furnished to me by that provider of service and (or) supplier.
I authorize any holder of medical information about me to release to the
Centers for Medicare and Medicaid Services and its agents any information
needed to determine these benefits or the benefits payable for related service."
(Beneficiary Signature) (Date)When using this procedure, the provider of service and (or) supplier must:
1. Complete and submit the appropriate Medicare billing form for all services covered by the request for payment, even when the provider of service and (or) supplier has not accepted assignment.
2. Incorporate, by stamp or otherwise, on any bill sent to the beneficiary, information to the effect "Do not use this bill for claiming Medicare benefits. A claim has been or will be submitted to Medicare for you."
3. Cancel the authorization at the request of the patient.
4. Make the patient signature files available for carrier inspection upon request. (Highmark Medicare Services will conduct periodic audits of signature files on a random basis.) Completion of this item is required for all claims.
ITEM 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE
The patient’s signature or the statement "signature on file" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a "signature on file" is not required in order for Medicare payment to be made directly to the physician or supplier.
The presence of or lack of a signature or "signature on file" in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.
In addtion, the signature in this item authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
Completion of this item is conditional for Medigap.
Note: If you wish to report the statement "Signature on File" in item 13 in lieu of the patient's actual signature, the following statement must be signed and dated by the patient and maintained in your records.< /p>
(Name of Beneficiary) (Health Insurance Claim Number) (Medigap Policy Number)
I request that payment of authorized Medigap benefits be made either to me or
on my behalf to the provider of service and (or) supplier for any services furnished
to me by that the provider of service and (or) supplier. I authorize any holder of
Medicare information about me to release to (Name of Medigap Insurer) any
information needed to determine these benefits payable for related services.
(Signature) (Date)ITEM 14 DATE OF CURRENT ILLNESS
Enter the six - digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six - digit date (MMDDYY) of the initiation of the course of treatment and enter the six - digit date (MMDDYY) x-ray date in item 19.
Reminder: For date fields other than date of birth, all fields shall be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCTT). Intermixing the two formats on the claim is not allowed
Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.
Completion of this item is required for all chiropractic services; conditional for other services.
ITEM 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS
Leave blank. Not required by Medicare.
ITEM 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
Enter the six - digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this item may indicate employment related insurance coverage.
Completion of this item is conditional for disability information.
ITEM 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.
Referring Physician - A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician - A physician, when appropriate, a non-physician practitioner who orders nonphysician services for the patient. Refer to Publication 100-2, Chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment and services incident to that physician's or non-physician practitioner's service.
All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name and NPI.
The following situations/services require the submission of the referring/ordering provider information:
- Parenteral and enteral nutrition;
- Immunosuppressive drugs claims;
- Hepatitis B claims;
- Diagnostic laboratory services;
- Diagnostic radiology services;
- Consultative services;
- Durable medical equipment.
- When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);
- When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;
- When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;
ITEM 17a Form CMS-1500 (08-05) – Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17.
Note: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.
ITEM 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.
Note: Item 17a and/or 17b is required when a service was ordered or referred by a physician.
Note: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.
ITEM 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
Enter the six - digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Completion of this item is conditional for medical services related to hospitalization.
ITEM 19 RESERVED FOR LOCAL USE
Enter the six - digit (MMDDYY) or an 8-digit (MM/DD/CCYY) date the patient was last seen and the NPI/PIN of his/her attending physician when a physician providing routine foot care submits claims.
Chiropractic
A physical examination may be used to document subluxation if an xray is not used. Report all that apply by using the letters P, A, R and/or T; orEnter the six - digit (MMDDYY) or an 8-digit (MM/DD/CCYY) x-ray date for chiropractor services. By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor is certifying that the relevant information requirements are on file (including level of subluxation) of Pub 100-2. Medicare Benefit Policy Manual, Chapter 15, are on file, along with the appropriate x-ray and all are available for review.
Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.
Unlisted Drug Codes
Enter the drug's name and dosage when submitting a claim for a "not otherwise classified" (NOC) drugs.Unlisted procedure code or not otherwise classified (NOC) codes
Enter a concise description of an unlisted procedure code (an NOC code) or a "not otherwise classified" code if one can be given within the confines of this box. Otherwise an attachment shall be submitted with the claim.Homebound
Enter the statement "Homebound" when an independent lab renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services From Independent Labs, Physicians, and Providers," and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)Assigned Benefits
Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim.Hearing Aid
Enter the statement, "testing for hearing aid" when billing services involving the testing of a hearing aid is used to obtain intentional denials when other payers are involved.Dental
When dental exams are billed, enter the specific surgery for which the exam is being performed.Post-Operative Care
Enter the six - digit assumed and/or relinquished date (MMDDYY) for a global surgery claim when providers share postoperative care.Hospice
Enter the statement, "Attending physician, not hospice employee" when a physician renders services to a hospice patient but the hospice providing the patient's care (in which the patient resides) does not employ the attending physician.Demonstration ID Number
Enter demonstration ID number "30" for all national emphysema treatment trial claims.Purchased Interpretation of a Diagnostic Test
Enter the PIN/NPI of the physician who is performing a purchased interpretation of a diagnostic test. (See Pub. 100-04, Chapter 1, Section 30.2.9.1 for additional information)Note: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.
Method II Suppliers
Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis. (See Pub. 100-04, Chapter 8, Section 60.7.2).Completion of this item is conditional as described above.
ITEM 20 OUTSIDE LAB
Complete this item when billing for purchased diagnostic tests. Enter the purchase price under charges if the"YES" item is checked. A "YES" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "NO" check indicates that "no purchased tests are included on the claim". When "YES" is annotated, item 32 must be completed. When billing for multiple purchased diagnostic tests, each test must be submitted on a separate claim form. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as the appropriate line level information is submitted when services are rendered at different service facility locations.
Note: Do not report the ZP modifier with diagnostic services. If the technical portion of the diagnostic services was NOT purchased, item 20 should be checked "NO". If the technical portion of the diagnostic servicewas purchased, items 20 and 32 of the CMS-1500 claim form must be completed to meet purchased service criteria.< /p>
Completion of this item is conditional for diagnostic tests.
ITEM 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Effective for services performed on or after October 1, 2003, the use of ICD-9-CM diagnosis codes is required on all claims submitted to Medicare Part B; except for those claims submitted by ambulance suppliers.
Enter the patient's diagnosis/condition. Use an ICD-9-CM diagnosis code number and code to the highest level of specificity for the date of service. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory shall enter a diagnosis only for limited coverage procedures.
All narrative diagnosis codes for nonphysician specialties shall be submitted on an attachment.
The International Classification of Diseases, Clinical Modification (ICD-9-CM) is the coding system which must be used.See Chapter 1, section 1.13, for information on how to obtain an ICD-9-CM diagnosis code book.
Note: For services performed prior to 10/01/2003, an independent laboratory was required to enter a diagnosis only for limited coverage procedures.
Completion of this item is required for all claims, other than those submitted by ambulance suppliers.
ITEM 22 MEDICAID RESUBMISSION
Leave blank. Not required by Medicare.
ITEM 23 PRIOR AUTHORIZATION NUMBER
Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
Enter the Investigational Device Exemption (IDE) when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable.
For physicians performing care plan oversight services, enter the six-digit Medicare provider number of the home health agency (HHA) or hospice when CPT codes G0181 and G0182 are billed.
Note: Effective immediately, CMS is temporarily waiving the requirement to include the HHA or Hospice provider number on a CPO claim since there is currently no place on the HIPAA Standard ASC X12N 837 Professional Format to specifically include the HHA or Hospice number. To prevent claims from being returned as unprocessable DO NOT submit the HHA or Hospice number on EMC or CMS 1500 claim forms until further notice.
Enter the ten - digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.
When a physician provides services to a beneficiary residing in a SNF and the services were rendered to a SNF beneficiary outside of the SNF, the physician shall enter the Medicare facility provider number of the SNF in item 23.
Note: Item 23 can contain only one condition. Any additional conditions should be reported on a separate Form CMS-1500.
Completion of this item is conditional.
ITEM 24 (FORM CMS-1500 (08-05)
The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines. At this time, the shaded area is not used by Medicare. Future guidance will be provided on when and how to use this shaded area for the submission of Medicare claims.
ITEM 24A DATES OF SERVICE
Enter the six or eight - digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.
Completion of this item is required for all claims; all lines of service.
ITEM 24B PLACE OF SERVICE
Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed.
Note: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.
Completion of this item is required for all claims; all lines of service.
POS Code/Name Description
03/School A facility whose primary purpose is education.
04/Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).
05/Indian Health Service Free-standing Facility A facility or location owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.
Not applicable for adjudication of Medicare claims.06/Indian Health Service Provider-based Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. Not applicable for adjudication of Medicare claims.
07/Tribal 638 Free-Standing Facility A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization. Not applicable for adjudication of Medicare claims.
08/Tribal 638 Provider-Based Facility A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. Not applicable for adjudication of Medicare claims.
11/Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
12/Home Location, other than a hospital or other facility, where the patient receives care in a private residence.13/Assisted Living Facility Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services.
14/Group Home A residence, with shared living areas, where clients receive supervision and other services, such as social and/or behavioral services, custodial services, and minimal services (e.g. medical administration).
15/Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
16/Temporary Lodging (April 1, 2008) A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.
20/Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
21/Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22/Outpatient Hospital A portion of a hospital, which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23/Emergency Room-Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24/Ambulatory Surgical Center A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
25/Birthing Center A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants.
26/Military Treatment Facility A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
31/Skilled Nursing Facility A facility, which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32/Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
33/Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.34/Hospice A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
41/Ambulance—Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42/Ambulance—Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
49/Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
50/Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51/Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52/Psychiatric Facility-Partial Hospitalization A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53/Community Mental Health Center A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54/Intermediate Care Facility/Mentally Retarded A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
55/Residential Substance Abuse Treatment Facility A facility, which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56/Psychiatric Residential Treatment Center A facility or distinct part of a facility for psychiatric care, which provides a total 24-hour therapeutically, planned and professionally staffed group living and learning environment.
57/Non-residential Substance Abuse Treatment Facility A location, which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
60/Mass Immunization Center A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.
61/Comprehensive Inpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62/Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
65/End-Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
71/State or Local Public Health Clinic A facility maintained by either State or local health department that provides ambulatory primary medical care under the general direction of a physician.
72/Rural Health Clinic A certified facility, which is located in a rural medically, underserved area that provides ambulatory primary medical care under the general direction of a physician.
81/Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.
99/Other Place of Service Other place of service not identified above.
ITEM 24C TYPE OF SERVICE
Not required by Medicare. Leave blank.
ITEM 24D PROCEDURES, SERVICES, OR SUPPLIES
Enter the procedures, services or supplies using the CMS Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.
Enter the acquisition cost for pharmaceutical or radiopharmaceutical diagnostic imaging agents or for therapeutic radionuclides. This is required in order to receive reimbursement. Please specify that the dollar amount listed is the acquisition cost.
Item 24DPROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS | MODIFIER
A9500 | Acquisition Cost = $120.00Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment shall be submitted with the claim. This is a required field.
Claim(s) will be returned as unprocessable if an "unlisted procedure code" or an (NOC) code is indicated in item 24d, but an accompanying narrative is not present in item 19 or on an attachment.
ITEM 24E DIAGNOSIS CODEEnter the diagnosis code reference number as shown in item 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in item 21.
Completion of this item is required for all claims, other than those submitted by ambulance suppliers.
ITEM 24F ($) CHARGES
Enter the charge for each listed service.
Completion of this item is required for all claims (all lines of service).
ITEM 24G DAYS OR UNITS
Enter the number of days or units. This item is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages or allergy testing procedures). When multiple services are provided, enter the actual number provided.
For anesthesia, show the elapsed time (minutes) in item 24G. Convert hours into minutes and enter the total minutes required for this procedure.
Suppliers must furnish the units of oxygen contents except for concentrators and initial rental claims for gas and liquid oxygen systems. Rounding of oxygen contents is as follows:
- For stationary gas system rentals, suppliers must indicate oxygen contents in unit multiples of 50 cubic feet in item 24G, rounded to the nearest increment of 50. For example, if 73 cubic feet of oxygen were delivered during the rental month, the unit entry "01" indicating the nearest 50 cubic foot increment is entered in item 24G.
- For stationary liquid systems, units of contents shall be specified in multiples of 10 pounds of liquid contents delivered, rounded to the nearest 10 pound increment. For example, if 63 pounds of liquid oxygen were delivered during the applicable rental month billed, the unit entry "06" is entered in item 24G.
- For units of portable contents only (i.e., no stationary gas or liquid system used) round to the nearest five feet or one liquid pound, respectively.
Completion of this item is required for all claims; (all lines of service).
ITEM 24H EPSDT FAMILY PLANNING
Leave blank. Not required by Medicare.
ITEM 24I Form CMS-1500 (12-90)
Leave blank. Not required by Medicare.
ITEM 24I Form CMS-1500 (08-05)
Enter the ID qualifier 1C in the shaded portion.
ITEM 24J Form CMS-1500 (12-90)
Leave blank. Not required by Medicare.
ITEM 24J Form CMS-1500 (08-05)
Enter the rendering provider’s NPI in the shaded portion.
In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion.
Enter the rendering provider's NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unsahded portion.
*NOTE: Applicable during the Medicare Fee-for-Service Contingency Plan - subject to change once the Contingency is lifted.
Note: Effective May 23, 2008, the shaded portion of 24J is not to be reported.
ITEM 24K Form CMS-1500 (08/05)
There is no Item 24K on this version.ITEM 25
Enter the provider of service or supplier Federal Tax ID (Employer Identification Number) or Social Security Number. The participating provider of service or supplier Federal Tax ID number is required for a mandated Medigap transfer.
ITEM 26 PATIENT'S ACCOUNT NUMBEREnter the patient's account number assigned by the provider of service and (or) supplier's accounting system. This is an optional item to enhance patient information.
ITEM 27 ACCEPT ASSIGNMENT
Check the appropriate item to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in item 9 and MEDIGAP payment authorization is given in item 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.
The following provider of service and (or) supplier claims can only be paid on an assignment basis:
- Clinical diagnostic laboratory services;
- Physician services to individuals dually entitled to Medicare and Medicaid;
- Participating provider of service and (or) supplier services;
- Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers;
- Ambulatory surgical center services for covered ASC procedures;
- Home dialysis supplies and equipment paid under Method II;
- Ambulance Services;
- Drugs and biologicals; and
- Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine
ITEM 28 TOTAL CHARGE
Enter the total charges in Block 28 for all services reported on each CMS 1500 claim form (i.e., total of all charges from item 24F). All CMS 1500 claim forms will be treated individually, therefore when documentation is required it must be submitted for each CMS 1500 claim form. Claims not submitted in this manner will be returned to the provider. Refer to Chapter 18, section 10.3 for instructions on roster billing for mass immunizations as these are excluded from this requirement. Chapter 18, section 10.3.1 explains how roster billing should be submitted.
Some examples of claims that would be returned are claims indicating:
"Continued", "next"; "see next page" or a single total for multiple CMS 1500 claim forms in Block 28
Multiple 1500 claim forms requiring the same attachment require photocopies for each individual claim form (i.e. explanation of benefits (EOB); operative reports; medical records)
Completion of this item is required for all claims.
ITEM 29 AMOUNT PAID
Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges.
Completion of this item (i.e., amount paid or "$0.00") is required for all claims.
ITEM 30 BALANCE DUE
Leave blank. Not required by Medicare.
ITEM 31 SIGNATURE OF THE PROVIDER OF SERVICE AND (OR) SUPPLIER INCLUDING DEGREE OR CREDENTIALS
Enter the signature of the provider of service and (or) supplier, or his/her representative, and either the six - digit date (MMDDYY), eight-digit date (MMDDCCYY), or alpha-numeric date (e.g., January 1, 2007) the form was signed.
In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.
Completion of this item is required for all claims. Note: This is a required field; however, the claim can be processed if the following is true. If a physician, supplier, or authorized person’s signature is missing, but an authorization is attached to the claim or if the signature field has a computer generated signature or if "signature on file" is indicated. A computer generated “signature” that does not name an individual person is not acceptable. For example, “ABC Anesthesia Group” would not be considered an acceptable computer generated signature.
ITEM 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED FORM CMS -1500 (12-90)
Effective for claims received on and after April 1, 2004, all Medicare Part B claims must contain the name, street address, and ZIP code where the service was rendered in item 32 of the CMS 1500 claim form. Failure to report this information in item 32 will result in the claim being returned as unprocessable and you will not be afforded appeal rights. Only one name, address and zip code may be entered in this item. If additional entries are needed, separate claim forms shall be submitted.
Note: Even if you are reporting a service in your office, you must report this information in item 32. Please disregard the CMS 1500 claim form instructions for this item which tell you to report name and address of facility where services were rendered if other than home or office.
Enter the name and address including the ZIP code of the facility where the services were furnished. Providers of service (namely physicians) must identify the supplier's name, address and carrier assigned Provider Identification Number (PIN) when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS 1500 (12-90) claim form should be used to report and bill for each supplier. Purchases from out-of-state providers must be billed to the state where the service was actually performed.
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. Carriers processing foreign claims will have to make the necessary accommodations to verify that the claim(s) is not returned as unprocessable due to the lack of a ZIP code.
This item is completed whether the supplier personnel performs the work at the physician's office or at another location.
If a QB or QU modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA), the physical location where the service was rendered must be entered.
If the supplier is a certified mammography center, enter the six-digit FDA certification number. Also, complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed and the carrier assigned PIN. If more than one outside laboratory was used, a separate CMS-1500 (12-90) claim for must be completed for each supplier.
Completion of this item is mandatory, or the claim may be returned for ICR references.
ITEM 32 Form CMS-1500 (08-05)
Enter the name and address, and ZIP code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient’s home or physician’s office. Effective for claims received on or after April 1, 2004, the name, address, and zip code of the service location for all services other than those furnished in place of service home – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and zip code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted.
Providers of service (namely physicians) shall identify the supplier’s name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier.
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.
For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier. This item is completed whether the supplier’s personnel performs the work at the physician’s office or at another location. If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home.
Complete this item for all laboratory work performed outside a physician’s office. If an independent laboratory is billing, enter the place where the test was performed.
ITEM32a Form CMS-1500 (08-05)
If required by Medicare claims processing policy, enter the NPI of the service facility.ITEM 32b Form CMS-1500 (08-05)
If required by Medicare claims processing policy, enter the PIN of the service facility. Be sure to precede the PIN with the ID qualifier 1C. There should be one blank space between the qualifier and the PIN.Note: Effective May 23, 2008, Item 32b is not to be reported.
ITEM 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
Item 33 Form CMS-1500 (12-90)
Enter the physician’s individual/group or supplier’s billing name, address (physical location, no PO Boxes), ZIP code, and telephone number.Individual Provider
Enter the carrier assigned PIN # preceded by the two alpha characters (Not the CMS assigned UPIN) for the performing physician or supplier who is not a member of a group practice.Group Practices
Enter the carrier assigned GRP # preceded by the 2-digit alpha characters (the first two letters of the group name). Complete either the PIN # or GRP # field, not both.Completion of this item is required for all claims.
ITEM 33 Form CMS-1500 (08-05)
Enter the physician's individual/group or supplier's billing name, address (physical location, no PO Boxes), ZIP code, and telephone number. This is a required field.
ITEM 33a Form CMS-1500 (08-05)
Enter the NPI of the billing provider or group. This is a required field.
ITEM 33b Form CMS-1500 (08-05)
Enter the ID qualifier 1C followed by one blank space and then the NPI and/or legacy number of the billing provider or group. Suppliers billing the DME MAC will use the National Supplier Clearinghouse (NSC) number in this item.
Note: Effective May 23, 2008, Item 33b is not to be reported.
Individual Provider
Enter the carrier assigned PIN# or Medicare Legacy# and NPI#. (Not the CMS assigned UPIN) for the performing physician or supplier who is not a member of a group practice.
Group Practices
Enter the carrier assigned GRP# or Medicare Legacy# and NPI #. Complete either the PIN # and NPI# or GRP# and NPI# field, not both.
Completion of this item is required for all claims.
*NOTE: Applicable during the Medicare Fee-for Service Contingency Plan - subject to change once the contingency if lifted.
9.4 Join CMS in Saving Medicare Trust Funds
The Centers for Medicare and Medicaid Services (CMS) is continuing efforts to reduce costs and administrative waste. As of 4/1/96, a new editing process will be implemented for assigned claims which will save the Medicare Trust Fund millions of dollars. For some time, the denial of claims with incomplete or invalid information has resulted in claims surfacing inappropriately into the appeals process. This practice has not only been costly, it has resulted in an inappropriate use of the appeals system.
This new editing process will return paper or electronic claims to you as unprocessable if the claim contains certain incomplete or invalid information. No appeal rights will be afforded to these claims, or portion of these claims, because no "initial determination" can be made rendering the claim unprocessable.
This new editing process not only saves Medicare Trust Funds, there is little change and no additional administrative burdens for you. You will not be denied any services you are accustomed to. You will be able to correct an unprocessable claim under the new editing system with the same ease as you did under the current system. If you are accustomed to submitting corrections via the telephone, on a development letter, as a new claim, or in any format, that process will continue. However, you will not be granted a review because "returned" claims have no appeal rights.
One caution: Please correct "returned" claims promptly because only when that is done will you have met your legal obligation for submitting a Medicare claim. If you are a non-participating provider and currently bill beneficiaries prior to submitting a claim, you may continue to do so.
What does Return as Unprocessable mean?
Returning a claim as unprocessable does not mean your Medicare carrier will physically return every claim you submit with incomplete or invalid information. The term "return as unprocessable" is used to refer to the many processes utilized by your Medicare carrier today for notifying you that your claim cannot be processed, and that it must be corrected or resubmitted. Some (not all) of the various techniques for returning claims as unprocessable
include:1. Incomplete or invalid information is detected at the front-end of your Medicare carrier's claims processing system. The claim is returned to you either electronically or in a hardcopy/checklist type form explaining errors and how to correct them.
2. Incomplete or invalid information is detected at the front-end of the claims processing system and is suspended and developed by your Medicare carrier. If corrections are submitted within a 45 day period, the claim is processed. Otherwise, the suspended portion is "returned as unprocessable" and you are notified by means of the remittance notice.
3. Incomplete or invalid information is detected within the claims processing system and is returned for ICR references through the remittance process by your Medicare Carrier. You are notified of any error(s) through the remittance notice, as well as how to correct it.
Note: An incomplete claim is a claim with missing, required information (e.g., no UPIN). An invalid claim is a claim that contains complete and necessary information; however, the information is illogical or incorrect (e.g., incorrect UPIN).
What information will be provided to assist you in correcting a claim?
To assist you in furnishing the appropriate corrections, the following information will be supplied (as long as it is on the received claim):
1) Beneficiary's name;
2) HIC number;
3) Dates of service;
4) Patient account or control numberAn explanation of the errors will also be provided. This explanation will either be in the form of a description or a code.
Which Incomplete or Invalid Information will be Returned as Unprocessable?
The following information will be returned as unprocessable if it is not completed and/or entered accurately on the claim. Please note that a required data element must always be present on a claim (Refer to Exhibit I).
To assist you in completing your claim:
Refer to Exhibit I for details on items or conditional information that will cause a claim to be returned for ICR references. For paper claims, refer to Chapter 9, section 9.3 of the Medicare Part B Reference Manual; for electronic claims, refer to Chapter 10. Please verify that your printing specifications are correct on a claim. Claims will be returned as unprocessable if the required information is submitted incorrectly.
Special Note: If you do not submit information for a required or conditional item(s) because the information is normally kept on file with your Medicare carrier, and can be supplied by your Medicare carrier, then the claim will not be returned as unprocessable.
Your claim will be returned for ICR references:
1. If a service was ordered or referred by a physician (other than those services specified below) and the physician's name and/or UPIN (or surrogate) is not present in items 17 or 17a.
2. If a physician extender or other limited licensed practitioner refers a patient for consultative services, but the name and/or UPIN of the supervising physician is not entered in items 17 or 17a.
3. For diagnostic tests subject to purchase price limitations
- If a "YES" or "NO" is not indicated in item 20.
- If the "YES" box is checked in item 20 and the purchase price is not entered under the word "$CHARGES".
- If the "YES" box is checked and the purchase price is entered under $CHARGES, but item 32 is blank (no name or PIN number is provided).
4. If a diagnosis code listed in item 21 is missing, invalid or truncated or if the narrative diagnosis is not listed on an attachment.
5. If modifiers "QB" and "QU" are entered in item 24D to refer to a Health Professional Shortage Area, but item 32 is left blank, or contains no facility/laboratory name or carrier assigned PIN.
6. If a performing physician/supplier/or other practitioner is a member of a group practice and does not enter his or her carrier assigned Provider Identification Number (PIN) in item 24K and the group number in item 33.
7. If a primary insurer to Medicare is indicated in item 11, but items 4, 6, and 7 are incomplete.
8. If there is insurance primary to Medicare that is indicated in item 11 by either an insured/group policy number or the FECA number, but the insurance/program name in item 11c is incomplete.
9. For chiropractor claims:
a. If the x-ray date(s) is not entered in item 19.
b. If the initial date "actual" treatment began is not entered in item 14.
10. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and they do not enter the group's name or billing number in item 33 and their personal PIN number in item 24K.
11. For durable medical, orthotic, and prosthetic claims, if the name or PIN of the location where the order was accepted is not entered in item 32.
12. For physicians who maintain dialysis patients and receive a monthly capitation payment:
a. If the physician is a member of a professional corporation, similar group, or clinic, and the attending physician's PIN is not entered in item 24K.
b. If the name or PIN of the facility involved with the patient's maintenance of care and training is not entered in item 32.
13. For foot care claims, if the date the patient was last seen and the attending physician's UPIN are not present in item 19.
14. For immunosuppressive drug claims, if a referring/ordering physician was used and their name and/or UPIN are not present in items 17 or 17a.
15. For all laboratory services, if the services of a referring/ ordering physician are used and his or her name and/or UPIN are not present in items 17 or 17a.
16. For laboratory services performed by participating hospital-leased laboratory or an independent laboratory (including services to a patient at home or in an institution), if the name or PIN of the laboratory where services were performed is not in item 32.
17. For independent laboratory services involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if a prescribing physician does not validate any laboratory service(s) performed at home or in an institution by entering the appropriate annotation in item 19 (i.e. - "Homebound").
18. For mammography "screening" and "diagnostic" claims, if a qualified screening center does not accurately enter their six-digit, FDA-approved facility identification number in item 32 when billing the technical or global component.
19. For physician assistant, nurse practitioner, and clinical nurse specialist claims, if services are performed in a hospital setting but neither the hospital's name or PIN is entered accurately in item 32.
20. For parenteral and enteral nutrition claims, if the services of an ordering/referring physician(s) are used and their name and/or UPIN is not present in item 17 or 17a.
21. For portable X-Ray services claims, if the ordering physician's name and/or UPIN are not entered in items 17 or 17a.
22. For radiology and pathology claims for hospital inpatients, if the referring/ordering physician's name and/or UPIN (if appropriate) are not entered in items 17 or 17a.
23. For outpatient services provided by a qualified, independent physical or occupational therapist:
a. If the UPIN of the attending physician is not present in item 19.
b. If the date the patient was last seen by the attending physician is not present in item 19.
24. If a HCPCS modifier must be associated with a HCPCS procedure code or if the HCPCS modifier is invalid.
If my claim is returned as unprocessable through the remittance notice, how will I be notified of the error(s)?
Medicare Inpatient Adjudication (MIA)/ Medicare Outpatient Adjudication (MOA)/Reference Remark Codes that will be used if your claim is returned as unprocessable through the remittance process. Please note that MIA/MOA Code MA130 will be present on the remittance notice for any claim returned for incomplete or invalid information.
Note: For free listing of Claim Adjustment Reason Codes and Remittance Remark Codes, please visit http://www.wpc-edi.com. If you do not have Internet access, you may contact the Washington Publishing Company at (301) 949-9740 to obtain copies; however, fees may apply.
Incomplete Claim: A claim submitted with missing required information (i.e., - no provider number, no patient telephone number or at least 000-000-0000 for an unlisted telephone number).
Invalid Claim: A claim that contains complete and necessary information; however, the information is illogical or incorrect.
The following are a few examples of either invalid or incomplete data element returns for ICR references:
- A claim billed for a referred service is missing the referring physician information (blocks 17 and 17a),
- Incomplete or invalid use of modifiers is reported in block 24D,
- A member of a group practice does not submit the rendering provider identification number (PIN) in block 24K,
- Incomplete or invalid diagnosis codes are used on physician claims (block 21),
- Patient's relationship to insured is not completed (block 6),
- The insurance that is primary to Medicare is indicated, but the insurance plan/program name is incomplete (block 11c), or
- An anesthesiology claim is submitted and the elapsed time from patient prep to personal attendance is not included; (block 24G), or there is no indication if the service was medically directed, personally performed or medically supervised (block 24D).
Exhibit 1
The law prohibits Medicare carriers to extend appeal rights for claims that contain incomplete or invalid information. No notice of appeal rights will be furnished in connection with the returned claim for ICR references because no "initial determination" on the claim was made. No beneficiary Explanation of Medicare Benefits (EOMB) will be issued for a returned claim.
You cannot bill the beneficiary for the services; the claim must be corrected and resubmitted through the normal claim filing procedures.
If a claim is returned for ICR references, you will receive notification on your normal provider voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim.
Note: For EMC billers, all existing batch and claim level returns for ICR references will be retained. The PCLR 5001-5004 reports should be utilized for these returns.
d. CMS-1500 (12-90) Claim Form
If a claim is returned for incomplete or invalid information, the service must be resubmitted. Please refer to Exhibit 1, the CMS-1500 claim form for submission requirements chart. Do not submit a returned service for a review. No written or telephone appeals will be offered. There will be no Explanation of Medicare Benefits (EOMB) forwarded to beneficiaries for a claim that Highmark Medicare Services' has determined to be "unprocessable".
The following is a description of the data element items indicated on the example CMS-1500 (12-90) claim form:
Required (R): Completion of this item is mandatory forall claims submitted to Medicare for processing.
Conditional (C): Completion of this item is dependent on various circumstances, as in the examples below:
1. If Medigap is involved, blocks 9, 9a, 9c, and 9d must be completed.
2. If non-physician services are ordered for a patient, the name and UPIN of the ordering physician must be entered in blocks 17 and 17a.
3. If diagnostic tests subject to purchase price limitations are reported, block 20 must be completed.
Optional (O): Completion of this item will not result in an incomplete or invalid claim return; however, we encourage you to fill in each block on a CMS-1500 (12-90) claim form.
9.5 Mandatory Claim Submission
When Congress passed the Omnibus Budget Reconciliation Act of 1989, it included a requirement that all providers of service and (or) supplier submit complete/valid claims on behalf of Medicare beneficiaries for services furnished on or after September 1, 1990. Congress believed this would yield more accurate information with which to evaluate Medicare expenditures and other factors such as volume and intensity of services under the Medicare Volume Performance Standard (MVPS). The standard is Congress' primary tool for managing the growth in Medicare Part B expenditures for physician services.
Providers of service and (or) supplier must file with the Medicare carrier all claims for services and supplies provided to Medicare beneficiaries. The time limits for filing are as follows:
For Services Rendered Between:
Your Claim Must Be Submitted By:
Oct. 1, 2004 and Sept. 30, 2005
December 31, 2006
Oct. 1, 2005 and Sept. 30, 2006
December 31, 2007
Oct. 1, 2006 and Sept. 30, 2007
December 31, 2008
Claims submitted outside of these time frames will be denied as untimely.
In order for a request for payment to be considered to have been filed timely, it must not be considered to be unprocessable under the definition found in the CMS Manual-Publication 100-4, Chapter 1, Sections 80.3.1-80.3.2.. Highmark Medicare Services returns unprocessable claims to the provider. Such returns do not constitute claims nor satisfy the timely filing requirements. In those instances, a processable claim must be resubmitted within the timely filing period.
- Medicare assigned claims must be filed within one year from the service date or the payment will be reduced by 10%. The time limits for filing Medicare Part B claims are that the claim can be filed in the year the service was rendered; plus a year following the year for the service. Services rendered in the quarter from October through December are deemed rendered in the following year.
- All paper Medicare claims must be submitted on the CMS-1500 (08-05) claim form which is printed in red drop out ink.
- For assigned claims processed on or after October 1, 1995, claims returned due to incomplete/invalid claim data will require correction and resubmission by the provider.
- For non-assigned claims processed on or after January 1, 1996, claims returned due to incomplete/invalid claim data will require correction and resubmission by the provider regardless of the date of service.
- The claims filing requirement applies to all providers of service and (or) supplier who provide services to Medicare beneficiaries. If a beneficiary requires a determination for a non-covered service, the provider of service and (or) supplier must submit the claim.
- Providers of service and (or) supplier are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Provider of service and (or) supplier Program or the Medicare beneficiary is also a recipient of state Medical Assistance (Medicaid).
- Providers of service and (or) supplier may not charge the beneficiary for preparing and filing a Medicare claim.
- Highmark Medicare Services will monitor provider of service and (or) supplier compliance with the Medicare claims filing requirements.
- Providers of service and (or) supplier who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation.
b. Mandatory Claims Filing Does not Affect the Following:
Physician/Supplier/Beneficiary Payment Arrangements:Providers of service and (or) supplier who do not accept assignment may continue to request payment in full at the time that the service is provided. We encourage you to file the claims at the same time you request payment. This will reduce a potential financial hardship for the patient and reduce future inquiries to you about the status of the claim.
Non-Covered Medicare Services:Providers of service and (or) supplier must file claims on behalf of Medicare beneficiaries for non-covered services in order to get the information necessary to submit to other insurers upon the beneficiary's request.