box number 1 – 4 – How to fill and instruction – upperright hand portion important

CMS-1500 Claim Form Completion for Ambulance Providers

You must follow these instructions to complete the CMS-1500 claim when billing the Department of Public Welfare. Do not imprint, type, or write any information on the upperright hand portion of the form. This area is used to stamp the Internal Control Number (ICN),which is vital to the processing of your claim. Do not submit a photocopy of your claim to Medical Assistance.

BlockNo.	Block Name	Block Code	Notes
1	Type of Claim	M	Place an X in the Medicaid box.
1a	Insured’s ID Number	M	Enter the 10-digit recipient number found on the ACCESS card. If the recipient number is not available, access the Eligibility Verification System (EVS) by using the recipient’s Social Security Number (SSN) and date of birth (DOB). The EVS response will then provide the 10-digit recipient number to use for this block.
2	Patient’s Name	A	It is recommended that this field be completed to enable Medical Assistance (MA) to research questions regarding a claim. *This field is required when billing for newborns using the mother’s recipient number. Enter the newborn’s name. If the first name is not available, you are permitted to use Baby Boy or Baby Girl.
3	Patient’s Birthdate and Sex	A	Enter the patient’s date of birth using an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 02151978) and indicate the patient’s gender by placing an X in the appropriate box. *Same as the special instruction for Block 2. Enter the newborn’s date of birth in an eight-digit format.
4	Insured’s Name	A	If the patient has health insurance other than MA, list the name of the insured here. Enter the name of the insured except when the insured and the patient are the same – then the word SAME may be entered. If there is no other insurance other than MA, leave this block blank.