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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.5 CMS‑1500 Paper Claim Filing Instructions : 6.5.4 CMS‑1500 Instruction Table

6.5.4
CMS‑1500 Instruction Table
The instructions describe what information must be entered in each of the block numbers of the CMS‑1500 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.
 
Insured’s ID No. (for program checked above, include all letters)
For other property & casualty claims: Enter the Federal Tax ID or SSN of the insured person or entity.
Enter the client’s last name, first name, and middle initial as printed on the Medicaid identification form.
If the insured uses a last name suffix (e.g., Jr, Sr) enter it after the last name and before the first name.
Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the client’s gender by checking the appropriate box.
If the client is deceased, enter “DOD” in block 9 and the time of death in 9a if the services were rendered on the date of death. Enter the date of death in block 9b.
Check the appropriate box. If other insurance is available, enter appropriate information in blocks 11, 11a, and 11b.
If another insurance resource has made payment or denied a claim, enter the name of the insurance company. The other insurance EOB or denial letter must be attached to the claim form.
For Workers Compensation and other property and casualty claims: (Required if known) Enter Workers’ Compensation or property and casualty claim number assigned by the payer.
Patient’s or authorized person’s signature
Enter “Signature on File,” “SOF,” or legal signature. When legal signature is entered, enter the date signed in eight digit format (MMDDYYYY).
Enter the first date (MM/DD/YYYY) of the present illness or injury. For pregnancy enter the date of the last menstrual period.
Enter the name (First Name, Middle Initial, Last Name) and credentials of the professional who referred, ordered, or supervised the service(s) or supplies on the claim. If multiple providers are involved, enter one provider using the following priority order:
Do not use periods or commas within the name. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported.
If there is a Supervising Physician for the referring or ordering provider that is listed in Block 17, the name and NPI of the supervising provider must go in Block 19.
If the claim is part of a multiple transfer, indicate the other client’s complete name and Medicaid number.
If there is a Supervising Physician for the referring or ordering provider that is listed in Block 17, the name and NPI of the supervising provider must go in Block 19.
Check the appropriate box. The information may be requested for retrospective review.
Enter the applicable ICD indicator to identify which version of ICD codes is being reported.
Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity.
For Workers Compensation and other property and casualty claims, this is required when prior authorization, referral, concurrent review, or voluntary certification was received.
Unless otherwise specified, all required information should be entered in the unshaded portion.
If more than six line items are billed for the entire claim, a provider must attach additional claim forms with no more than 28-line items for the entire claim.
For multi-page claim forms, indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the claim form.
Enter the date of service for each procedure provided in a MM/DD/YYYY format. If more than one date of service is for a single procedure, each date must be given on a separate line.
The 11-digit NDC number on the package or vial from which the medication was administered. Do not enter hyphens or spaces within this number (e.g., 00409231231).
Example:
EMG (THSteps medical checkup condition indicator)
Fully describe procedures, medical services, or supplies furnished for each date given
Enter the appropriate procedure codes and modifier for all services billed. If a procedure code is not available, enter a concise description.
In the shaded area, enter a 1- through 12-digit NDC quantity of unit. A decimal point must be used for fractions of a unit (e.g., 0.025).
In 24 E, enter the diagnosis code reference letter (pointer) as shown in Form Field 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference number for each service should be listed first, other applicable services should follow.
Indicate the usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay clients.
If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).
In the shaded area, enter the NDC unit of measurement code. There are 5 allowed values: F2, GR, ML, UN or ME.
Enter the provider identifier of the individual rendering services unless otherwise indicated in the provider specific section of this manual.
Optional: Enter the client identification number if it is different than the subscriber/insured’s identification number.
For multi-page claims enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim.
Note: Indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.
Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in block 11. If the client makes a payment, the reason for the payment must be indicated in block 11.
Billing services may print “Signature on File” in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.
If services were provided in a place other than the client’s home or the provider’s facility, enter name, address, and ZIP code of the facility where the service was provided. This is a required field for services provided in a facility. The facility provider number, name, and address are not optional.

Texas Medicaid & Healthcare Partnership
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