How to report billed amount in CMS 1500 24F $ Charges

Enter the provider’s usual and customary fee (amount charged to a person who is not a MassHealth member). Enter the amount rightjustified in the dollar area of the field. Do not use commas or dollar
signs when reporting dollar amounts. Do not enter negative dollar amounts. Enter “00” in the cents area if the amount is a whole number.

For Medical Supplies:

If billing for medical supplies that do not require prior authorization and are listed in Subchapter 6 (service codes and descriptions) of your MassHealth provider manual as not requiring individual consideration (IC) and do not require prior authorization, enter the actual acquisition cost and attach a copy of the supplier’s invoice to the claim. Invoices submitted with a claim must be dated no more than 18 months before the date of service.

For Medications and Injectables:
Enter the actual acquisition cost and attach a copy of the supplier’s invoice to the claim. Invoices submitted with a claim must be dated no more than 18 months before the date of service.