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50 Cards in this Set
- Front
- Back
Carrier block is located ________________ |
Upper right corner |
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Block 1 is ___________________ |
Type of Insurance for this filing of claim (payer you are sending this claim to) |
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Block 1a ____________________ |
Insured's I.D. Number (insurance being filed on this claim form) Note: if pt has unique ins ID number, then put that here |
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Block 2.________________________ |
Patient's Name (Last, First, Middle Initial) - Must be same as on insurance card! Can use commas to separate names. |
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Block 3._______________________ |
Patient's Birth Date (8-digit format, no punctuation used) MMDDYYYY |
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Block 4.______________________ |
Insured's Name (Last, First, Middle Initial) - as on insurance card (can use commas) |
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Block 5._______________________ |
Patient's Address (use no punctuation except hyphen for 9 digit zip code) |
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Block 6._________________________ |
Patient Relationship to Insured |
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Block 7. _______________________ |
Insured's Address (no punctuation except hyphen for 9 digit zip code) |
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Block 9. _______________________ |
Secondary Ins Information: 9.Other Insured's Name (Last, First, MI) a. Other Insured's Policy or Group No b. and c. (reserved for NUCC use) d. Insurance Plan Name or Program Name Note: this info is for secondary insurance on current claim |
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Block 10. _____________________ |
Patient's condition caused by: Check all boxes appropriate to tell what pt's condition is related to. Not checking anything could cause claim to be rejected or denied |
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Block 11.__________________________ |
Insured's Policy Group or FECA Number a. Insured's Date of Birth, sex b. Other claim ID c. Insurance Plan Name or Program Name d. Is there another health benefit Plan? If this is checked yes, then complete items 9, 9a, 9d |
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Block 12.____________ |
Authorization for release of PHI to process claim. NOTE: this block ALSO functions as assignment of benefits for Medicare, Tricare, and Champva (gov't benefits). If completed with SOF, must include date that signature is on file. |
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Block 13. _________________________ |
Signature for assignment of benefits, private-pay insurances. If completed with SOF, must include date that signature is on file. |
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Information in blocks 1 through 13 is known as _________________ |
Patient and Insured Information |
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Information BELOW black line, blocks 14 through 33, is known as _____________ |
Physician or Supplier information |
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Block 14. _______________________ |
Date of current illness, injury, or pregnancy LMP Note: if there is date here, must be 3-digit qualifier after dotted line. For example, LMP would be 484, date of current illness, 431. |
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Block 15.___________________________ |
Other date that applies to illness. Needs qualifier if used. |
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Block 16. ______________________ |
Dates patient unable to work in current occupation. If still in hospital, only From date will be completed. Generally used if this is worker comp claim, or if current claim reflects services due to hospitalization. |
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Block 17. _______________________ |
Name of Referring Provider or other source (First, Last, credential). Needs qualifier before dotted line if used. |
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Block 17a.______________________ |
NPI of person in block 17 (Referring Provider). If another number used, goes in shaded area with qualifier listed first. |
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Block 18. _______________________ |
Hospitalization date related to current
services. If still in hospital, only From date will be completed. |
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Block 20.________________________ |
Use this field when billing for purchased lab services by entering an X in “YES. This is if another lab furnishes services but you are charging for them. You must put the amt lab charges as well. Medicare does not allow mark-ups for lab services. CLIA waived tests are not included here. Put address in block 32 of laboratory who performs services. |
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Block 21. ________________________ |
Can put up to 12 DX codes here. Enter ICD indicator of 9 for ICD-9-CM, or 0 for ICD-10-CM used. |
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Block 22. _______________________ |
For resubmitted claim. Enter 7 or 8 to left of line, original reference number from original claim to right of line. (7 - resubmit original, 8 void/cancel original) |
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Block 23._______________________ |
Enter Payer Authorization Number for a pre-authorized service |
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Block 24a.____________________ |
Date of Service info. Do not need to put same date twice in same line. |
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Block 24b. _____________________ |
Enter Place of Service 2-digit code. |
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Block 24c.____________________ |
Check with payer to see if emergency indicator is necessary. Otherwise, leave blank. |
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Block 24d._____________________ |
Procedures, services, or supplies. Enter CPT/HCPCS code, up to 4 modifiers. Only 6 service lines can be entered per form. Gray lines are for special additional info. |
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Block 24e._____________________ |
DX Pointer: Properly link your dx codes to services here!! Can use up to 4 letters to designate dx's that are appropriate. List primary dx first. |
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Block 24f._________________________ |
List charge for service here |
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Block 24G________________________ |
List days or units of service(s) |
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Block 24h.______________________ |
Put Y here for yes if service is EPSDT; otherwise, leave blank. |
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Block 24I._____________________ |
Enter ID qualifier if you use a number other than NPI in 24J. Put the non-NPI number in the gray area in 24J, and put the ID qualifier in 24I in the gray area. |
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Block 24J.________________________ |
Put rendering provider ID # here |
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Block 25.______________________ |
Put Federal Tax ID number, check appropriate box. NPI number does NOT go here! |
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Block 26.____________________ |
Put patient account number here |
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Block 27.______________________ |
Accept assignment? Check yes or no. This must be reported for all payers. Note: box 13 is patient's permission, this box is provider's acceptance. |
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Block 28. ______________________ |
Put total charges of all services in 24F column. |
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Block 29.___________________________ |
Put amount paid by patient for COVERED SERVICES (i.e., copay), and/or for secondary claims, amount paid by primary insurance or other payers. |
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Block 31._____________________ |
In 5010A1, this info doesn't exist. Therefore, only need to put on form if you are sending paper claim that won't be converted to electronic format. Can then put in SOF or signature of physician or supplier with credentials listed. |
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Block 30._____________________ |
Reserved for NUCC use |
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Block 32.__________________________ |
Service Facility Location Info Must be used if put yes in block 20. This must be external organization to the billing provider. |
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Block 33.________________________________ |
Name, Address, City, State, Zip Code of billing provider. Phone number (no hyphens) in upper right space. Use hyphen for 9 digit zip code. This should ALWAYS be completed. |
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Block 33a.________________________________ |
NPI of billing provider. |
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Block 33b.________________________________ |
Non-NPI ID number Only used if required by payer. Use 2 digit qualifier in front of number to designate what type of non-NPI number you are using. |
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Official color of ink used to print CMS 1500 |
RED |
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Official type set and size used to complete CMS 1500 form |
10-pitch PICA. Also, form must be completed in ALL CAPS per UCR standards. (Universal Character Recognition) |
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Block 19.________________________ |
Many claim details can be entered in block 19 under CMS guidelines, and for requests from private payers. For instance, if modifier 99 used, all the additional modifiers may be listed here per NUCC guidelines. |