List of provider should use CMS 1500 form

The following providers must use the ASC X12N 837 5010 professional format when submitting electronic claims and the CMS 1500 claim form for paper claims.

* Ambulance

* Ambulatory Surgical Centers

* Anesthesiologist Assistants

* Certified Nurse Midwives

* Certified Nurse Practitioners

* Certified Registered Nurse

Anesthetists

* Chiropractors

* Community Mental Health Services Programs/Prepaid Inpatient Health Plans

* Family Planning Clinics

* Federally Qualified Health Centers

* Hearing Aid Dealers

* Hearing Centers

* Independent Laboratories

* Indian Health Centers

* Maternal Infant Health Program

* Medical Clinics

* Medical Suppliers

* Optical Companies

* Optometrists

* Oral-Maxillofacial Surgeons

* Orthotists and Prosthetists

* Physician Assistants

* Physical Therapists

* Physicians (MD & DO)

* Podiatrists

* Private Duty Nurses (Individually Enrolled)

* Rural Health Clinics

* School Based Services

* Shoe Stores

* Urgent Care Centers

Claims for services rendered as a result of an order or referral must contain the name and individual NPI of the provider who ordered or referred the service/item. The following are the authorized health professionals who may order, prescribe or refer services to Medicaid beneficiaries:

* Physician

* Physician Assistant

* Nurse Practitioner

* Certified Nurse Midwife

* Dentist

* Podiatrist

* Optometrist

* Chiropractor (limited to spinal x-rays only)

Examples of services that require an order, prescription or referral include, but are not limited to,:

* Ambulance non-emergency transports

* Ancillary services for beneficiaries residing in nursing facilities (e.g., chiropractic, dental, podiatry, vision)

* Childbirth/parenting and diabetes self-management education

* Consultations

* Diagnostic radiology services, unless rendered by the ordering physician

* Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

* Hearing and hearing aid dealer services

* Home health services

* Hospice services

* Laboratory services

* Certain mental health and substance abuse children’s waiver services

* Certain Maternal Infant Health Program (MIHP) services

* Pharmacy services

* Private Duty Nursing services

* Certain School Based Services

* Therapy services (occupational therapy (OT), physical therapy (PT) and speech)

* Certain vision supplies