Box 17 – 23 – How to file the claim – CMS 1500
Box 17a – Optional
Referring Provider Number
�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).
Box 17b – Optional
Referral National Provider Identifier (NPI)
�� If information was entered in box 17a (Primary Care Manager, or other referral) the corresponding NPI is entered here.
�� Enter the ten-digit NPI of the referring provider.
Box 21 – Required
Diagnosis Code
�� Enter the client’s diagnosis/condition.
�� The diagnosis code must be the reason chiefly responsible for the service being provided as
shown in medical records.
�� You may enter up to four codes and they must be carried out to its highest degree of specificity.
�� Do not use the decimal point.
Note: Diagnosis codes are not required for transportation providers.
Box 23 – Optional
Prior Authorization Number
�� If the service you provided requires prior authorization (PA), enter the ten-digit prior authorization number that was issued for the service.
�� Only use one prior authorization number per claim form.
�� Do not bill prior authorized and non-authorized services on the same claim form.
Box 17a – Optional
Referring Provider Number
�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).
Box 17b – Optional
Referral National Provider Identifier (NPI)
�� If information was entered in box 17a (Primary Care Manager, or other referral) the corresponding NPI is entered here.
�� Enter the ten-digit NPI of the referring provider.
Box 21 – Required
Diagnosis Code
�� Enter the client’s diagnosis/condition.
�� The diagnosis code must be the reason chiefly responsible for the service being provided as
shown in medical records.
�� You may enter up to four codes and they must be carried out to its highest degree of specificity.
�� Do not use the decimal point.
Note: Diagnosis codes are not required for transportation providers.
Box 23 – Optional
Prior Authorization Number
�� If the service you provided requires prior authorization (PA), enter the ten-digit prior authorization number that was issued for the service.
�� Only use one prior authorization number per claim form.
�� Do not bill prior authorized and non-authorized services on the same claim form.