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 noneed to complete the To Date.
R
24b PLACE OF SERVICE
Enter the HCFA standard place of service code. R24c 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 thepointers 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 R24g DAYS OR UNITS
Enter quantity. Anesthesia services are to be entered in true minutes. R24h EPSDT FAMILY PLAN
Not Required24i ID QUAL
Not Required24j RENDERING PROVIDER NPI #
R25 FEDERAL TAX I.D. NUMBER
SSN/EIN
Physician or Supplier’s Federal Tax ID numbers R26 PATIENT’S ACCOUNT NO.
The physician’s billing account number R27 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
R29 AMOUNT PAID
REQUIRED when another carrier is the primary payer. Enter the paymentreceived 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
R32 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 punctuatethe 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
1 comment:
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