Healthcare Billing InstructionHere R and C indicates Required and conditional respectively.
24a DATE (S) OF SERVICE From dateMMDDYY. If the service was performed on one day there is no
need to complete the To Date.
24b PLACE OF SERVICEEnter the HCFA standard place of service code. R
24c EMG R
24d PROCEDURES, SERVICES OR SUPPLIES
Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of
24e DIAGNOSIS POINTERDiagnosis 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.
24f CHARGESEnter charges R
24g DAYS OR UNITSEnter quantity. Anesthesia services are to be entered in true minutes. R
24h EPSDT FAMILY PLANNot Required
24i ID QUALNot Required
24j RENDERING PROVIDER NPI #R
25 FEDERAL TAX I.D. NUMBERPhysician 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.
28 TOTAL CHARGER
29 AMOUNT PAIDREQUIRED 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.
30 BALANCE DUE REQUIREDwhen # 29 is completed C
31 SIGNATURE OF PHYSICIAN ORR
SUPPLIER INCLUDING DEGREES
32 SERVICE FACILITY LOCATIONREQUIRED unless #33 is the same information. Enter the physical location.
(P.O. Box #’s are not acceptable here.)
32b UNLABELED FIELD
33 BILLING PROVIDER INFO ANDEnter the complete name and address of the physician. Do not punctuate
PHONE # (include area code)
the address or phone number.
PIN #: Enter Horizon NJ Health assigned individual physician ID. GRP #:
Enter Horizon NJ Health assigned group physician ID.
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