BOX 31 to BOX 33 – Detailed review

31 Signature Signature of person authorized to certify this claim. By signing the BMS Provider Enrollment Agreement providers have certified that all information listed on a claim for reimbursement from Medicaid is true, accurate and complete. Therefore, claims may be endorsed with a computer-generated, manual or stamped signature.

date Enter the claim submission date.

Box 31 

• Enter the rendering provider’s name and date

 − Provider should be registered with AHCCCS under the NPI submitted in 24J
− May be an individual provider or the group agency

 • If individual provider, name needs to match exactly with the name that is registered with AHCCCs and match the Agency Roster (if roster is applicable).

32 Service Facility Location Information

Enter name and address of rendering site, if patient was seen in institutional setting. (Hospital, Nursing Home, etc.)

32 A&B Servicing Facility NPI

A. Enter in the Servicing Facilities NPI
B. Non applicable

33 Billing Provider Info and Phone number

Enter required information as followed: Phone Name Address City, State & 9 digit zip code

33A NPI number of Physician or Supplier 

Enter the NPI of the servicing or rendering provider or group or pay-to. If the servicing /rendering is in 24j then enter in the servicing providers group number.

33B Taxonomy code of Physician or Supplier

Enter ZZ (qualifier) if you are entering in a taxonomy code for the pay-to No spaces between qualifier and value.