Block 12. The patient or authorized representative must sign and date this Block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with §§3047.7-3047.3. If the patient is physically or mentally unable to sign, a representative specified in §3008 may sign on the patient’s behalf. Block 13. The signature in this Block authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Block 9 and its subdivisions. The patient or his/her authorized representative signs this Block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked. Blocks 14-33 – Provider of Service or Supplier Information Block 14. Enter the date of current illness, injury, or pregnancy. For chiropractic services, enter the date of the initiation of the course of treatment and enter the X-ray date in Block 19. Block 15. Leave it blank. Not required by Medicare. Block 16. Enter dates if patient is employed and unable to work in current occupation. An entry in this field may indicate employment related insurance coverage. Block 17. Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Block17a – Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available. Block 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available.
Block 18. Complete this Block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Block 19. Enter the date, the patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.
Block 20. Complete this Block when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the “yes” block is checked. Block 21. Enter the patient’s diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity. Block 22. Leave it blank. Not required by Medicare. Block 23. Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval. Block 24a. Enter the month, day and year for each procedure, service, or supply. Block 24b. Enter the appropriate place of service code from the list provided in §2010.3. Identify the location where the Block is used or the service is performed. NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code. Block 24c. Medicare providers are not required to complete this Block. Block 24d. Enter the procedures, services or supplies using the CMS Common Procedure Coding System (HCPCS). Block 24e. Enter the diagnosis code reference number as shown in Block 21, to relate the date of service and the procedures performed to the primary diagnosis. Block 24f. Enter the charge for each listed service. Block 24g. Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, or anesthesia minutes. If only one service is performed, the numeral “1” must be entered. Block 24h. Leave it blank. Not required by Medicare. Block 24i. Leave it blank. Not required by Medicare. Block 24j. Enter the NPI of the performing provider of service/supplier if they are a and member of a group practice. Block 24k. Enter the first two digits of the NPI in Block 24j. Enter the remaining six digits of the NPI in Block 24k, including the two-digit location identifier. When several different providers of service or suppliers within a group are billing on the same CMS-1500, show the individual NPI in the corresponding line Block. Block 25. Enter your provider of service or supplier Federal Tax I.D. (Employer Identification Number) or Social Security Number. Block 26. Enter the patient’s account number assigned by the provider of service’s or suppliers accounting system. This field is optional to assist you in patient identification. As a service, any account numbers entered here will be returned to you. Block 27. Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. Block 33. Enter the provider of service/supplier’s billing name, address, zip code, and telephone number. Enter the NPI, including the 2-digit location identifier, for the performing provider of service/supplier who is not a member of a group practice. Chapter 12 Review and Assign QuestionsWhen a patient is covered by a large employer group health plan (EGHP) and Medicare, which is primary? When a child who is covered by two or more plans lives with his married parents, the primary policyholder is the parent whose birthday occurs first in the year. When an insurance company uses the patient's SSN as the patient's insurance identification number, Block 1a of the CMS-1500 contains the identification number without hyphens or spaces. When the CMS-1500 claim requires spaces in the data entry of a date, the entry looks like which of the following? When completing a CMS-1500 claim using computer software, text should be entered in ______ case. When the CMS-1500 claim require a response to YES or NO entries, enter When SIGNATURE ON FILE is the appropriate entry for a CMS-1500 claim block, which is also acceptable as an entry? Block 14 of the CMS-1500 claim requires entry of the date the patient first experienced signs or symptoms of an illness or injury (or the date of last menstrual period of obstetric visits). Upon completion of Jean Mandel's claim, you notice that there is Blocks 24A-24J of the CMS-1500 contain shaded rows, which can contain supplemental information, per payer instructions. Block 24A of the CMS-1500 claim contains dates of service (FROM and TO). If a procedure was performed on May 10, YYYY, in the office, what is entered in the TO block? Nancy White's employer provides individual and family group health plan coverage, and it pays 80% of her annual premium. Nancy selected family coverage for her group health plan, which means her employer pays $12,000 per year (of the $15,000 annual premiu When Block 25 of the CMS-1500 contains the provider's EIN, enter ______ after the first two digits of the EIN. When a patient is covered by the same primary and secondary commercial health insurance plan, submit just one CMS-1500 to the payer. When entering the patient's name in Block 2 of the CMS-1500 claim, separate the last name, first name, middle initial (if known) with When the patient is the domestic partner of the primary policyholder, this is indicated on the CMS-1500 claim form by...... placing an X in the OTHER box of block 6 When an insurance claim is submitted to an insurance company that covers the treatment of injured sustained in a motor vehicle accident, the _________ reviews the claim and determines coverage for the injured person. What is the correct way to enter the provider's name and credential in Block 31? A secondary health insurance plan generally provides coverage that is ........ similar to that of a primary health insurance plan. Which is considered a commercial health insurance company? Another term that can be used to indicate a fee-of-service plan is a ______ plan. When a patient is covered by a large employer group health plan (EGHP), and the patient is also a Medicare beneficiary, ________ is primary. Logan is the daughter of Amy (DOB 3/29/68) and Bill (BOD 11/15/70) and is covered by both parents' health insurance plans. According to the birthday rule, a medical claim for Logan will be submitted to Amy's plan as primary payer and Bill's plan as secondary payer. When the patient is the domestic partner of the primary policyholder, this is indicated on the CMS-1500 claim by placing an X in the OTHER box of Block 6. Reimbursement for income lost as a result of a temporary or permanent illness or injury is covered by ________ insurance. The patient was seen in the provider's office on 12/03/YYYY for an injury sustained four months earlier. What is entered in Block 14 of the CMS-1500 claim? What is entered in Block17b of the CMS-1500 claim? national provider identifier (NPI) Dr. Smith evaluates Marcia Brady during a three-month recheck of her diabetes mellitus. He performs venipunture and sends the patient's blood sample to an outside laboratory for testing of the blood glucose level. Dr. Smith's insurance specialist enters t If the patient has paid a copayment on the claim being submitted, this is indicated on the CMS-1500 claim by entering the When an insurance claim is submitted to an insurance company that covers the treatment of injuries sustained in a motor vehicle accident, the ______ reviews the claim and determines coverage for the injured person. Beatrice Blue holds a private commercial health care policy, and she wishes to have payment from health insurance company sent directly to her provider. How is this reported on the CMS-1500? Beatrice Blue will sign Block 13. Which claims are submitted to cover the cost of medicare for traumatic injures, lost wages, pain, and suffering? A balance of $12.55 is due to the patient for services provided by Dr. Brown. What is entered in Block 30 of the CMS-1500 claim? When the same commercial payer issues the primary and secondary or supplemental policies, it is generally acceptable to submit ______ claim(s). When laboratory tests are performed in the office, enter an X in the NO box of Reimbursement for loss of or damage to a vehicle (e.g. caused by fire, flood, hail, theft, vandalism, or wind) is covered by _______ (automobile) insurance. Which health plan is required to accept employees and their family members? What is entered in Block 24J if the provider is a member of a group practice? national provider identifier (NPI) |
What is entered in Block 24J if the provider
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