CMS 1500 – complete instruction to fill the claim
*1a. INSURED’S I.D. NUMBER: Enter the Medicaid client’s complete eleven-digit identification number (Example: 123456789-01). When billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child, enter the Medicaid number of the unborn child (see 471 NAC 1-002.02K).
*2. PATIENT’S NAME: Enter the full name (last name, first name, middle initial) of the person that received services.
*3. PATIENT’S BIRTHDATE AND SEX: Enter the month, day, and year of birth of the person that received the services. Check the appropriate box (M or F).
4. INSURED’S NAME: Complete only when billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child. Enter the Medicaid client’s name as it appears on the Nebraska Medicaid Card. This is the name of the person (the unborn child) whose number appears in Field 1a.
9. – 14. Fields 9-11 and 14 address third party resources other than Medicaid or Medicare. If there is no known insurance coverage, leave blank. If the client has insurance coverage other than Medicaid or Medicare, complete fields 9-11 and 14. A copy of the remittance advice, explanation of benefits, denial, or other documentation is required and must be attached to the claim. Nebraska Medicaid must review all claims for possible third party reimbursement. All third party resources must be exhausted before Medicaid payment may be issued.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE: Enter the name of the referring/prescribing physician.
17a. OTHER ID#: Leave qualifier field blank. Enter the license number of the referring physician in the shaded area of the large box in 17a. License number listings are available from the Medicaid Division. License numbers may also be accessed on the HHS web site: www.hhs.state.ne.us/med/medindex.htm. Click on “Pharmacy Program.”
17b. NPI #: Optional. Enter the NPI number of the referring provider, ordering provider or other source.
21. DIAGNOSIS OR NATURE OF ILLNESS OF INJURY: The services on this claim form must be related to the diagnosis entered in this field. Enter the appropriate International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis codes.
The COMPLETE diagnosis code is required. (A complete code may include the third, fourth, and fifth digits, as defined in ICD-9-CM). If there is more than one diagnosis, list the primary diagnosis first.
22. MEDICAID RESUBMISSION: Leave blank. For regulations regarding resubmittal or adjustment requests, see 471 NAC 3-000 and 471-000-99.
23 PRIOR AUTHORIZATION NUMBER: If the service requires prior authorization, enter the prior authorization number. This number must be entered to receive payment for a service or supply that requires prior authorization. Prior authorization requirements for hearing aid services are contained in 471 NAC 8-004.01.
If the service does not require prior authorization, leave blank.
*24. The six service lines in section 24 have been divided horizontally to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 services lines. Only six line items can be entered in Field 24. Do not print more than one line of information on each claim line. DO NOT LIST services for which there is no charge.
*24A. DATE(S) OF SERVICE: In the unshaded area, enter the 8-digit numeric date of service rendered. Each procedure code/service billed requires a date. Each service must be listed on a separate line. The “From” date of service must be completed. The “To” date of service may be left blank.
*24B. PLACE OF SERVICE: In the unshaded area, enter the place of service code 11 (office). National place of service codes are defined by the Centers for Medicare and Medicaid Services (CMS) and published on the CMS web site at http://www.cms.hhs.gov.
*24D. PROCEDURES, SERVICES, OR SUPPLIES: In the unshaded area, enter the appropriate HCPCS procedure code and, if required, procedure code modifier. Up to four modifiers may be entered for each procedure code. HCPCS procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-508). When using miscellaneous and not otherwise classified (NOC) procedure codes, a complete description of the service is required in the shaded area between 24D through 24H, as an 8 ½ x 11 attachment to the claim, or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims.
Procedure Codes: HCPCS procedure codes and procedure code modifiers used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-508). Local procedure codes W0220 – W0223 are not valid with dates of service beginning October 16, 2003.
24E. DIAGNOSIS POINTER: In the unshaded area, enter the diagnosis code reference number as shown in Field 21 (1-4).
*24F. $ CHARGES: Enter the lab invoice cost for hearing aids and hearing aid repairs. Enter the fee schedule maximum allowable fee for dispensing fees. Enter your customary charge for other procedures. Do not list one charge for several procedure codes.
*24G. DAYS OR UNITS: Enter the number of services being claimed. If the procedure code description includes specific time or quantity increments, each increment should be billed as one unit of service.
NOTE: Batteries are billed per battery not per package of batteries. Medicaid allows a maximum of 16 batteries per aid dispensed on a date of service.
*25. FEDERAL TAX I.D. NUMBER: Leave blank.
26. PATIENT’S ACCOUNT NO.: Optional. Any patient account information (numeric or alpha) may be entered in this field to enhance patient identification. This information will appear on the Medicaid Remittance Advice.
*28. TOTAL CHARGE: Enter the total of all charges in Field 24, Column F. If more than one claim form is used to bill for services provided, EACH claim form must be submitted with the line items totaled. DO NOT carry charge forward to another claim form.
*29. AMOUNT PAID: Enter any payments made, due, or obligated from other sources for services listed on this claim. Other sources may include health insurance, liability insurance, excess income, etc. A copy of the Medicare or insurance remittance advice, explanation of benefits, denial, or other documentation must be attached. DO NOT enter previous Medicaid payments, copayment or the difference between the provider’s billed charge and the Medicaid allowable (provider “write-off” amount) in this field.
*30. BALANCE DUE: Enter the balance due. (This amount is determined by subtracting the amount paid in Field 29 from the total charge in Field 28.)
*31. SIGNATURE OF PHYSICIAN OR SUPPLIER: The provider or authorized representative must SIGN and DATE the claim form. A signature stamp computer generated or typewritten signature will be accepted.
The signature date must be on or after the date(s) of service listed on the form.
*33. BILLING PROVIDER INFO & PHONE # ( ): Enter the provider’s name, address, zip code, and phone number.
33a. NPI #: Optional. Enter the NPI number of the billing provider.
33b. OTHER ID #: Enter the eleven-digit Nebraska Medicaid provider number as assigned by Nebraska Medicaid (example: 123456789-12). All payments are made to the name and address listed on the Medicaid provider agreement for this provider number.
Claim Attachments: For hearing aids and miscellaneous services, a copy of the purchase invoice must be attached to the claims or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims.
*1a. INSURED’S I.D. NUMBER: Enter the Medicaid client’s complete eleven-digit identification number (Example: 123456789-01). When billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child, enter the Medicaid number of the unborn child (see 471 NAC 1-002.02K).
*2. PATIENT’S NAME: Enter the full name (last name, first name, middle initial) of the person that received services.
*3. PATIENT’S BIRTHDATE AND SEX: Enter the month, day, and year of birth of the person that received the services. Check the appropriate box (M or F).
4. INSURED’S NAME: Complete only when billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child. Enter the Medicaid client’s name as it appears on the Nebraska Medicaid Card. This is the name of the person (the unborn child) whose number appears in Field 1a.
9. – 14. Fields 9-11 and 14 address third party resources other than Medicaid or Medicare. If there is no known insurance coverage, leave blank. If the client has insurance coverage other than Medicaid or Medicare, complete fields 9-11 and 14. A copy of the remittance advice, explanation of benefits, denial, or other documentation is required and must be attached to the claim. Nebraska Medicaid must review all claims for possible third party reimbursement. All third party resources must be exhausted before Medicaid payment may be issued.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE: Enter the name of the referring/prescribing physician.
17a. OTHER ID#: Leave qualifier field blank. Enter the license number of the referring physician in the shaded area of the large box in 17a. License number listings are available from the Medicaid Division. License numbers may also be accessed on the HHS web site: www.hhs.state.ne.us/med/medindex.htm. Click on “Pharmacy Program.”
17b. NPI #: Optional. Enter the NPI number of the referring provider, ordering provider or other source.
21. DIAGNOSIS OR NATURE OF ILLNESS OF INJURY: The services on this claim form must be related to the diagnosis entered in this field. Enter the appropriate International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis codes.
The COMPLETE diagnosis code is required. (A complete code may include the third, fourth, and fifth digits, as defined in ICD-9-CM). If there is more than one diagnosis, list the primary diagnosis first.
22. MEDICAID RESUBMISSION: Leave blank. For regulations regarding resubmittal or adjustment requests, see 471 NAC 3-000 and 471-000-99.
23 PRIOR AUTHORIZATION NUMBER: If the service requires prior authorization, enter the prior authorization number. This number must be entered to receive payment for a service or supply that requires prior authorization. Prior authorization requirements for hearing aid services are contained in 471 NAC 8-004.01.
If the service does not require prior authorization, leave blank.
*24. The six service lines in section 24 have been divided horizontally to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 services lines. Only six line items can be entered in Field 24. Do not print more than one line of information on each claim line. DO NOT LIST services for which there is no charge.
*24A. DATE(S) OF SERVICE: In the unshaded area, enter the 8-digit numeric date of service rendered. Each procedure code/service billed requires a date. Each service must be listed on a separate line. The “From” date of service must be completed. The “To” date of service may be left blank.
*24B. PLACE OF SERVICE: In the unshaded area, enter the place of service code 11 (office). National place of service codes are defined by the Centers for Medicare and Medicaid Services (CMS) and published on the CMS web site at http://www.cms.hhs.gov.
*24D. PROCEDURES, SERVICES, OR SUPPLIES: In the unshaded area, enter the appropriate HCPCS procedure code and, if required, procedure code modifier. Up to four modifiers may be entered for each procedure code. HCPCS procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-508). When using miscellaneous and not otherwise classified (NOC) procedure codes, a complete description of the service is required in the shaded area between 24D through 24H, as an 8 ½ x 11 attachment to the claim, or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims.
Procedure Codes: HCPCS procedure codes and procedure code modifiers used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-508). Local procedure codes W0220 – W0223 are not valid with dates of service beginning October 16, 2003.
24E. DIAGNOSIS POINTER: In the unshaded area, enter the diagnosis code reference number as shown in Field 21 (1-4).
*24F. $ CHARGES: Enter the lab invoice cost for hearing aids and hearing aid repairs. Enter the fee schedule maximum allowable fee for dispensing fees. Enter your customary charge for other procedures. Do not list one charge for several procedure codes.
*24G. DAYS OR UNITS: Enter the number of services being claimed. If the procedure code description includes specific time or quantity increments, each increment should be billed as one unit of service.
NOTE: Batteries are billed per battery not per package of batteries. Medicaid allows a maximum of 16 batteries per aid dispensed on a date of service.
*25. FEDERAL TAX I.D. NUMBER: Leave blank.
26. PATIENT’S ACCOUNT NO.: Optional. Any patient account information (numeric or alpha) may be entered in this field to enhance patient identification. This information will appear on the Medicaid Remittance Advice.
*28. TOTAL CHARGE: Enter the total of all charges in Field 24, Column F. If more than one claim form is used to bill for services provided, EACH claim form must be submitted with the line items totaled. DO NOT carry charge forward to another claim form.
*29. AMOUNT PAID: Enter any payments made, due, or obligated from other sources for services listed on this claim. Other sources may include health insurance, liability insurance, excess income, etc. A copy of the Medicare or insurance remittance advice, explanation of benefits, denial, or other documentation must be attached. DO NOT enter previous Medicaid payments, copayment or the difference between the provider’s billed charge and the Medicaid allowable (provider “write-off” amount) in this field.
*30. BALANCE DUE: Enter the balance due. (This amount is determined by subtracting the amount paid in Field 29 from the total charge in Field 28.)
*31. SIGNATURE OF PHYSICIAN OR SUPPLIER: The provider or authorized representative must SIGN and DATE the claim form. A signature stamp computer generated or typewritten signature will be accepted.
The signature date must be on or after the date(s) of service listed on the form.
*33. BILLING PROVIDER INFO & PHONE # ( ): Enter the provider’s name, address, zip code, and phone number.
33a. NPI #: Optional. Enter the NPI number of the billing provider.
33b. OTHER ID #: Enter the eleven-digit Nebraska Medicaid provider number as assigned by Nebraska Medicaid (example: 123456789-12). All payments are made to the name and address listed on the Medicaid provider agreement for this provider number.
Claim Attachments: For hearing aids and miscellaneous services, a copy of the purchase invoice must be attached to the claims or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims.