QMB eligibility only complete the CMS/HCFA 1500 claim form

Box 1: You must put an X in the Medicare box. This replaces the Y indicator used in 24 J on the old HCFA 1500.
Box 24D: Enter the procedure codes and modifiers normally billed to MaineCare.
Box 24F: Charges must reflect the sum of the Medicare coinsurance and deductible amounts as shown on the Explanation of Medicare Benefits (EOMB).
Box 28: Enter the total charges. This must equal the total of the individual line item charges in 24F.
Box 29: Enter any other third party payment from an insurance company. Do not enter the Medicare payment.
Box 30: Enter the balance due. This can not exceed the member responsibility shown on the Explanation of Benefits.

Attach a copy of the Explanation of Medicare Benefits (EOMB) and any
third party Explanation of Benefits (EOB).

Do not combine coinsurance / deductible charges with Medicare noncovered charges. Use one claim form for billing coinsurance / deductible charges and a separate claim for Medicare non-covered charges.

Box 1: Do not put an X in the Medicare box.
Box 24F: Charges must reflect your billed charges.
Box 29: Enter any other third party payment from an insurance
company.

Attach a copy of the Explanation of Medicare Benefits (EOMB) and any third party Explanation of Benefits (EOB)

Related Links :

• Electronic loop for patient name id sex

• Insurance id box 1a cms 1500

• How to submit cms 1500