Secondary claim submission CMS 1500 requirements

Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: (http://www.cms.hhs.gov/providers/edi/cms1500.pdf) Instructions for the completion of each block of the CMS-1500 are provided in this section. See page 20 for a reproduction of a CMS-1500 showing the reference numbers of Blocks. Blocks that refer to third party payers must be completed only if there is a third party payer other than Medicare or Medicaid.

The Medical Assistance Program is by law the “payer of last resort”. If a recipient is covered by other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim.

PROPER COMPLETION OF CMS-1500

For Medical Assistance processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

Block 1            –       Show all type(s) of health insurance applicable to this claim by checking the appropriate box(es).

Block 1a          –        INSURED’S ID NUMBER – Enter the patient’s Medicare number if applicable. The patient’s (recipient’s) 11-digit  Maryland Medical Assistance number is required in Block 9a. – Situational.

Block 2             –      PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Medical Assistance card. – Required

Block 3             –      PATIENT’S BIRTH DATE/SEX – Enter the patient’s (recipient’s) date of birth and sex. – Optional.

Block 4             –      INSURED’S NAME (Last Name, First Name, Middle Initial) – Enter the  name of the person in whose name the  third party coverage is listed, only when applicable. – Optional.

Block 5             –      PATIENT’S ADDRESS – Enter the patient’s (recipient’s) complete mailing address with zip code and telephone    number. – Optional.

Block 6               –       PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party  health insurance besides Medicare and Medicaid. – Optional.

Block 7                –          INSURED’S ADDRESS – When there is third party health insurance coverage besides Medicare and  Medicaid, enter the insured’s address and telephone number. – Optional.

Block 9a                –         OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the Patient’s (recipient’s) 11-digit Maryland   Medical Assistance number exactly as it appears on the MA card. The MA number must appear in this Block regardless of whether or  not a recipient has other insurance. Medical Assistance eligibility should    be verified on each date of service by calling EVS. EVS is operational 24 hours a day, 365 days a year at  the following number: 1-866-710-1447-Required

Block 11 INSURED’S POLICY GROUP OR FECA NUMBER – If the recipient has other third party health insurance and the claim has been rejected by that insurance, enter the appropriate rejection code  listed below: For information regarding recipient’s coverage, contact  Third Party Liability Unit at 410-767-1771. Required

  CODE    REJECTION REASONS

                      K      Services Not Covered
                      L       Coverage Lapsed
                      M      Coverage Not in Effect on Service Date
                      N      Individual Not Covered
                      Q      Claim Not Filed Timely (Requires documentation, e.g., a copy of rejection from the insurance company.)
                      R      No Response from Carrier Within 120 Days of Claim Submission (Requires documentation e.g., a statement indicating a claim submission but no response.)
                      S  Other Rejection Reason Not Defined Above (Requires documentation, e.g., a statement on the claim indicating that payment was applied to  the deductible.)

Block 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE –  Completion is optional if a valid Medical Assistance individual practitioner identification number is entered in Block #17a. To complete, enter the full name of the ordering practitioner. Do not submit an invoice unless there is an order on file that  verifies the identity of the ordering practitioner. Required

Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services.

Block 17a (gray ID NUMBER OF REFERRING PHYSICIAN – Enter the ID Qualifier – shaded area) 1D (Medicaid Provider Number) followed by the provider’s 9-digit Medicaid Provider Number. Required

Block 17b Enter the NPI of the referring, ordering, or supervising provider listed in Block 17. Required

Block 21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY – Enter  the 3, 4, or 5 character code from the ICD-9 related to the  procedures, services, or supplies listed in Block #24d. List the primary diagnosis on Line 1 and secondary diagnosis on Line 2. Additional diagnoses are optional and may be listed on Lines 3 and 4. Required.

Block 24 A-G (gray shaded area) NATIONAL DRUG CODE (NDC) – Report the NDC/quantity when billing for drugs using the J-code HCPCS. Allow for the entry of 61 characters from the beginning of 24A to the end of 24G. Begin by entering the qualifier N4 and then the 11-digit NDC number. It may be necessary to pad NDC numbers with left-adjusted zeroes in order to report eleven digits. Without skipping a space or adding hyphens, enter the unit of measurement qualifier followed by the numeric quantity administered to the patient. Below are the measurement qualifiers when reporting NDC units: Required.

                                                        Measurement Qualifiers

                                                       F2                   International Unit
                                                      GR                   Gram
                                                       ML                  Milliliter
                                                       UN                  Units

                      Example: NDC/Quantity Reporting
                     24A DATE(S) OF SERVICE                    D. PROCEDURES, SERVICES G. DAYS OR UNITS
                     ROM:                                     TO:                                CPT/HCPCS
                     MM DD YY                             MM DD YY                               –
                     N400009737604UN1                (SHADED AREA)                         –
                     01 01 08                                   01 01 08                                  J1055