Source of referral for admission or visit. FL 68: 0000049705 00000 n 0000070063 00000 n 0000043399 00000 n 0000074397 00000 n Enter the other provider name (last, first) in the bottom row. Enter the accommodation rate for room and board on inpatient claims, or the appropriate CPT/HCPCS code for the outpatient ancillary service being reported. 0000022153 00000 n 0000025592 00000 n 0000041749 00000 n 0000038284 00000 n Enter the amount, in dollars and cents, received toward payment of this bill prior to billing the insurance provider. 29 0 obj <> endobj 0000018249 00000 n 0000130571 00000 n hXKo#7+:`XH[/dm =Ipv/dCdHDqfa{h-1)-0R1#9cG0K U.S. Department of Health & Human Services hbbd```b``?A$bu^ "yj@$:{, `XdX 6s A federal government website managed by the 0000001311 00000 n 0000000016 00000 n 0000029539 00000 n 0000021521 00000 n 0000071322 00000 n 0001010524 00000 n 0000028054 00000 n 0000038614 00000 n 0000030364 00000 n 0000020444 00000 n 0000028714 00000 n 0000047381 00000 n 0000838900 00000 n 0000075399 00000 n 0000002729 00000 n 0000017633 00000 n 0000046053 00000 n 0000060826 00000 n Enter the policy holder's group name (s). 0000006295 00000 n FL 78-79: 0000072442 00000 n The site is secure. 0000033499 00000 n Enter the total charge amount for all items in the revenue code section on line 23. 0000083302 00000 n 0000062162 00000 n 0000037624 00000 n 0000135812 00000 n 0000040594 00000 n 0000069401 00000 n 0000078957 00000 n A late effect E-code may be used for subsequent visits when a late effect of the initial injury or poisoning is being treated. 0000002650 00000 n 0000077543 00000 n 0000061158 00000 n Enter the physician's ID number(s) on the top line and their name on the bottom line. 0000050701 00000 n 0000019978 00000 n 0000071815 00000 n 0000022208 00000 n 0000064022 00000 n trailer 0000019826 00000 n 0000045887 00000 n 0000024933 00000 n ]r= oU/{~EZ,G8MuS(9O8[Uo. 0000120376 00000 n 0000065399 00000 n 0000131066 00000 n 0000022317 00000 n 0000099352 00000 n 0000057175 00000 n 0000077616 00000 n 0000131859 00000 n 0000368490 00000 n Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers. 0000018714 00000 n FL 44: 0000002871 00000 n 0001029945 00000 n Enter any other ICD procedure codes that correspond to any other significant procedures performed during the patient encounter. 0000767926 00000 n 0000109929 00000 n xref 0000056345 00000 n Left-justify and enter up to 5 lines of information. 0000054187 00000 n Enter the appropriate assignment of benefits certification indicator. 0000131671 00000 n Enter any additional condition or occurrence codes. google_ad_client="ca-pub-2747199579955382";google_ad_slot="9869789507";google_ad_width=336;google_ad_height=280; Back from CMS 1450 Instructions to Medical Billing Tutorials 0000031424 00000 n Line C - Tertiary Payer. Enter the name of the individual on the insurance policy. This is done in alphanumeric order. 0000117029 00000 n %PDF-1.6 % Reserved for assignment by the National Uniform Billing Committee (NUBC). 0000088010 00000 n The following information is a guide to the CMS-1450; each section is not required by all insurance providers: FL 1: Enter the Billing Provider information in the following order -, FL 2: If different from FL 1, enter the address in which it is to be sent to. 0000046551 00000 n 0000053191 00000 n 0000135113 00000 n Note: Per the ICD-9-CM Official Guidelines for Coding and Reporting, E-codes should only be assigned to the initial treatment of an injury, poisoning, or adverse effect of drugs. startxref 0000114897 00000 n FL 13: 0000057341 00000 n 0000002389 00000 n 0000059333 00000 n 0000026902 00000 n 0 0000007359 00000 n 0000473103 00000 n 0000081651 00000 n startxref 0000046717 00000 n %%EOF 0000086676 00000 n 0000062657 00000 n %PDF-1.4 % 0000019673 00000 n 0000117855 00000 n 0000040759 00000 n For further information regarding E-codes please refer to the ICD-9-CM Official Guidelines for Coding and Reporting, which may be accessed at. %%EOF If employed, please state the employer's company name. 0000004181 00000 n 0000023141 00000 n FL 77: 0000048543 00000 n 0000023636 00000 n Enter the standard abbreviation descriptions for each revenue code. endstream endobj 30 0 obj<> endobj 31 0 obj<> endobj 32 0 obj<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>> endobj 33 0 obj<> endobj 34 0 obj<> endobj 35 0 obj[/ICCBased 49 0 R] endobj 36 0 obj<> endobj 37 0 obj<> endobj 38 0 obj<> endobj 39 0 obj<>stream 0000050867 00000 n 0001053550 00000 n Line B - Secondary Payer. 0000062492 00000 n 0000008567 00000 n Line C - Tertiary Payer. FL 38 (1-5): 0000084010 00000 n 0000082458 00000 n 0001000910 00000 n Line B - Secondary Payer. 0000019349 00000 n 0000021472 00000 n 0000076948 00000 n 0000150472 00000 n FL 52: Enter the beginning and ending service dates of the entire period covered in the claim in MMDDYY format. 0000021217 00000 n document.write(y+1900), Back from CMS 1450 Instructions to Medical Billing Tutorials, Line e: country code (use if outside the US). 0000029044 00000 n 0000033169 00000 n 0000007785 00000 n Leave Blank. 0000075905 00000 n !A/;rdo58`_c_ XSkJ3Lye;fP} VXD=6 >"(,S*Eye~gGqT0as1%C(APv[OuA5kHcj8\)7 S/MsV.tH`9[X&>iS02} -d+\ #~}^("{bhbl}." 7nM4 AG,EhE.8 %rPA h>3^Bd[ zEDub=_|UoSWEE7zTsH*[N6?^P\?{P In dollars and cents, enter the estimated amount due from Medica after prior payments are subtracted. 0000082131 00000 n Leave blank. The information necessary for claim completion is not universal amongst insurance providers. Enter the number assigned to the original claim by Medica when submitting an adjusted claim. 0000113857 00000 n 0000041419 00000 n Line A - primary payer. Leave blank. The ICD-9-CM diagnosis code that describes the patients diagnosis or reason for visit at the time of inpatient admission. Enter any additional information required by the payer for the claim to be processed. FL 6: 0000086765 00000 n FL 70: 0000047879 00000 n HUMoFW-4`wg?8ieEa SID"YI(;AZ09}[NAA90$R` _B9(O_V|;'LX}\c@) t~9YTy '*fC(mS~vT~f^KO_.c3l,>3)TQfY4u.uNIsVB#x 0000076422 00000 n 0000054353 00000 n 0000145071 00000 n 0000080461 00000 n 0000015229 00000 n Reserved for assignment by the National Uniform Billing Committee (NUBC). 0000042739 00000 n The decimal within the code is implied and does not need to be used. 0000626530 00000 n trailer Instructions for Completion of Form CMS-1450. 0000028219 00000 n For inpatient admission, enter the PPS (prospective payment system) code. Enter the healthcare ID number. 0000057009 00000 n 0000060163 00000 n Enter the policy holder's employer name. 0000023724 00000 n 0000072283 00000 n 0000052527 00000 n Enter the policy holder's group number(s). 0000105376 00000 n Enter the patient's sex - "M" for male, "F" for female, "U" for unknown. 0000063857 00000 n %PDF-1.6 % Enter patients date of birth in MMDDYYYY format. 0000058503 00000 n The provider type qualifiers are as follows: "DN" - referring provider; "ZZ" - other operating physician; "82" - rendering provider. hbbd```b``A$S!d&oH&0V"el03V9=DN,@U QH Line B - Secondary Payer. 0000043564 00000 n Remarks must be typewritten. 0000151024 00000 n 0000069071 00000 n 0000024451 00000 n 0000022481 00000 n 0000068209 00000 n 0000055681 00000 n 0000062327 00000 n 0000069236 00000 n 0000043212 00000 n 0000039769 00000 n 0000026417 00000 n 0000092452 00000 n An official website of the United States government. 0000066102 00000 n 0000082799 00000 n Enter the patient's medical/health record number assigned by the office. The first digit is a leading zero, The next 2 digits indicate the type of bill, The fourth digit indicates the frequency of the bill. 0000081131 00000 n 0000052361 00000 n 0000060660 00000 n 0000116523 00000 n .Gb1_4{_y2 KSZHWI}2g startxref 0000049373 00000 n Enter condition codes in alphanumeric order. Principal Dx Code and Present on Admission Indicator. 0000064559 00000 n 0000081792 00000 n Used to enter the operating physicians ID. You will need to submit an original or reproduced copy of the EOB or EOMB with a paper claim if Blue Cross is a secondary payer. 0000086809 00000 n 0000059665 00000 n Enter the policy holder's name. 0000092314 00000 n 0000018295 00000 n 0000104805 00000 n Enter the occurrence span dates in alphanumeric order using the "MMDDYY" format. 0000085388 00000 n %%EOF 0000001910 00000 n Used to indicate that a payer has authorized treatment. Line A - Primary payer. 0000031684 00000 n Enter the service units (this can be days, quantity of item, dosage, etc.). Line A - Primary payer. 0000018871 00000 n Line A - Primary payer. 0000068730 00000 n 0000063182 00000 n The ICD-9-CM code for the principal procedure and date performed. 0000105343 00000 n 0000056843 00000 n 0000026148 00000 n The name and service location of the provider submitting the bill. Washington, D.C. 20201 Enter any special notations that may be helpful in adjudicating the claim. |X CFHDW(ZIv. 0000064202 00000 n Enter patients complete mailing address including street number and name or P.O. Enter the HCPCS codes and any appropriate modifiers for outpatient claims. 0000054685 00000 n 0000148819 00000 n box or RFD; city; state; ZIP code. 0000007500 00000 n 0000013019 00000 n 0000065219 00000 n 0000078789 00000 n 0000059499 00000 n FL 73: 0000057507 00000 n Verify the required data fields with each insurance company before submitting a claim. 0000039604 00000 n 0000070375 00000 n Enter the correct 7-digit provider number as assigned by the insurance provider for the type of services provided. Inpatient claims require a POA (present on admission) indicator; use the following: "Y" - condition was present on admissions; "N" - condition not present on admission; "U" - no information on the record; "W" - condition was clinically undetermined. 0000027889 00000 n 0000046219 00000 n 29 23 0000080800 00000 n 0000051531 00000 n FL 65: 0000109448 00000 n 0000017143 00000 n 0000053523 00000 n 0000025098 00000 n 0000001442 00000 n 0000056179 00000 n 0000075235 00000 n Enter the total charge related to the revenue code subcategory listed in field 42. 0000042904 00000 n 0000049871 00000 n Enter the total number of accommodation days, ancillary units of service or visits as appropriate. 0000024606 00000 n FL 49: 0000020288 00000 n 0000054021 00000 n Left-justify up to 26 alphanumeric characters. 0000031536 00000 n FL 48: 0000056511 00000 n 0000045223 00000 n 0000082295 00000 n 0000017307 00000 n 0000077962 00000 n Leave Blank. 0000081294 00000 n 0000041254 00000 n Using the ICD-9-CM manual (or ICD-10 if it's in effect), enter the primary procedure code and date it was performed. 0000041584 00000 n Line C - Tertiary payer. 1-866-795-4975, 2001 - 2022 UB-04 Software, Inc. | Privacy Policy | Terms of Use | EULA | Sitemap, NUCC Releases 1500 Health Insurance Claim Form Reference Instruction Manual & Provider Taxonomy code set, Everything a Mental Health Provider Needs to Know about Billing, Tips for Completing the HCFA-1500 (CMS1500) Form, Billing provider name, address and telephone number (phone # and fax # desirable). Do not key the decimal point. 0000040924 00000 n 0000009675 00000 n 0000050037 00000 n Enter the appropriate release of information certification indicator. Line C - tertiary payer. Line C - Tertiary Payer. 0001018603 00000 n 0000008000 00000 n 0000065922 00000 n 0000464574 00000 n Enter and left-justify the 5-digit or 6-digit policy number if group coverage applies. 0000016391 00000 n 0000015581 00000 n 0000005384 00000 n Use the MMDDYY format when recording the date. 0000061831 00000 n 0000081458 00000 n 0000109253 00000 n 0000117881 00000 n 0000076966 00000 n 0000018096 00000 n 491 0 obj <> endobj 0000042244 00000 n Enter the valid member ID number exactly how it appears on the ID card. Report if number is different from the subscriber/insureds ID. FL 37: 0000883200 00000 n FL 74 (a-e): 0000067927 00000 n 0000076244 00000 n 0000721045 00000 n Enter any prior payments made by the patient. Each insurance provider requires different information to be completed. 0 0000080296 00000 n 0000171789 00000 n 0000063362 00000 n 0000431473 00000 n Patients reason for visit at the time of outpatient registration. 0000051199 00000 n 0000027549 00000 n 0000009502 00000 n Enter the physician's ID number(s) on the top line and their name on the bottom line. 0000075564 00000 n Enter occurrence codes in alphanumeric order along with the corresponding dates in "MMDDYY" format. 0000023545 00000 n X??Phpdhfab` @=C#=C82t31DplLP: * e0eY\ & n=CaIL q\ ^,vy?] n07AaR 0000973474 00000 n