Healthcare Billing

Healthcare Billing Instruction

Here R and C indicates Required and conditional respectively.

24a DATE (S) OF SERVICE From date

MMDDYY. If the service was performed on one day there is no
need to complete the To Date.
R

24b PLACE OF SERVICE

Enter the HCFA standard place of service code. R

24c EMG R

24d PROCEDURES, SERVICES OR SUPPLIES
CPT/HCPCS MODIFIER



Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of
service.
R

24e DIAGNOSIS POINTER

Diagnosis Pointer - Indicate the associated diagnosis by referencing the
pointers listed in field 21 (1,2,3, or 4). Diagnosis codes must be valid ICD-9
codes for the date of service.
R

24f CHARGES

Enter charges R

24g DAYS OR UNITS

Enter quantity. Anesthesia services are to be entered in true minutes. R

24h EPSDT FAMILY PLAN

Not Required

24i ID QUAL

Not Required

24j RENDERING PROVIDER NPI #

R

25 FEDERAL TAX I.D. NUMBER
SSN/EIN

Physician or Supplier’s Federal Tax ID numbers R

26 PATIENT’S ACCOUNT NO.

The physician’s billing account number R

27 ACCEPT ASSIGNMENT?

Always indicate Yes. Refer to the back of the CMS 1500 (HCFA 1500-12-90)

form for the section pertaining to Medicaid Payments.
R

28 TOTAL CHARGE

R

29 AMOUNT PAID

REQUIRED when another carrier is the primary payer. Enter the payment
received from the primary payer prior to invoicing Horizon NJ Health.
Medicaid programs are always the payers of last resort.
C
30 BALANCE DUE REQUIREDwhen # 29 is completed C

31 SIGNATURE OF PHYSICIAN OR
SUPPLIER INCLUDING DEGREES
OR CREDENTIALS/DATE

R

32 SERVICE FACILITY LOCATION
INFORMATON

REQUIRED unless #33 is the same information. Enter the physical location.
(P.O. Box #’s are not acceptable here.)
R
32a NPI
32b UNLABELED FIELD

33 BILLING PROVIDER INFO AND
PHONE # (include area code)

Enter the complete name and address of the physician. Do not punctuate
the address or phone number.
PIN #: Enter Horizon NJ Health assigned individual physician ID. GRP #:
Enter Horizon NJ Health assigned group physician ID.
R
33a NPI
33b UNLABELED FIELD


Example CMS 1500
CMS 1500 claim form billing instruction - Part 1
CMS 1500 billing instruction - Part 2
Healthcare Billing instruction part 3

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