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Form DFS-F5-DWC-9 (CMS-1500)

Applicable Services

Supporting Documentation

Required Attachments

Filling out the Form

Instructions

Service

Rule

Physician Services

Final 69L-7.720 Forms Incorporated by Reference for Medical Billing, Filing and Reporting 

Laboratory / Pathology

CMS-1500 Medical Bill

Required Documents

Treatment

Findings and plan of treatment pursuant to reporting requirements of the DFS-F5-DWC-25

Surgery

An operative report when a surgical procedure is performed

Consultation

A narrative report when a consultation or an independent medical examination is rendered

When requested at time of authorization

Copies of medical records, when requested at the time of authorization by the employer/carrier or designated entity, in order to determine the medical necessity of services that must be substantiated in more detail than previously disclosed

CMS-1500 Box #

CMS-1500 (02/12) Field Description

Florida Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Florida Workers' Compensation Instructions

0

CARRIER NAME AND ADDRESS

1

MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA, BLACK LUNG, OTHER

N

1a

INSURED’S I.D. NUMBER

R

Enter the Social Security Number or the Division-Assigned Number of the injured employee. If the Social Security Number is unknown and the Division-Assigned Number is also unknown, the provider must contact the insurer/claim administrator to obtain the number.

2

PATIENT’S NAME (Last Name, First Name, Middle Initial)

R

Enter injured employee’s last name, first name, and middle initial, if applicable.

3

PATIENT’S BIRTH DATE, SEX

R

Enter injured employee’s date of birth in MMDDYY format.

4

INSURED’S NAME (Last Name, First Name, Middle Initial)

R

Enter name of the employer.

5

PATIENT’S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

R

Enter the injured employee’s complete mailing address and telephone number in the appropriate spaces:

Line 1 – Enter the street address, including apartment number if applicable;

6

PATIENT RELATIONSHIP TO INSURED

N

7

INSURED'S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

R

Enter the complete business address of the employer entered in Field 4:

Line 1 – Enter the street address, including suite number if applicable;

Line 2 – Enter the city and state;

Line 3 – Enter the zip code and telephone number.

8

RESERVED FOR NUCC USE

N

9

OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)

N

9a

OTHER INSURED'S POLICY OR GROUP NUMBER

N

9b

RESERVED FOR NUCC USE

N

9c

RESERVED FOR NUCC USE

N

9d

INSURANCE PLAN NAME OR PROGRAM NAME

N

10a

IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT

R

Enter an “x” in the appropriate box (A,B,C) to indicate whether any of the billed services are for a condition covered by workers’ compensation insurance, an auto accident, or any other accident type

10b

IS PATIENT'S CONDITION RELATED TO: AUTO ACCIDENT _ PLACE (State)

R

Enter an “x” in the appropriate box (A,B,C) to indicate whether any of the billed services are for a condition covered by workers’ compensation insurance, an auto accident, or any other accident type

10c

IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT

R

Enter an “x” in the appropriate box (A,B,C) to indicate whether any of the billed services are for a condition covered by workers’ compensation insurance, an auto accident, or any other accident type

10d

CLAIM CODES (Designated by NUCC)

S

Enter Claim Codes as applicable.

CMS-1500 Box #

CMS-1500 (02/12) Field Description

Florida Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Florida Workers' Compensation Instructions

11

INSURED'S POLICY GROUP OR FECA NUMBER

N

11a

INSURED'S DATE OF BIRTH, SEX

N

11b

OTHER CLAIM ID (Designated by NUCC)

N

11c

INSURANCE PLAN NAME OR PROGRAM NAME

N

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

N

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

N

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

N

14

DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)

R

Enter the date of onset, in MMDDYY, i.e. date of first symptoms or current accident, illness or injury.

15

OTHER DATE

N

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

N

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE

N

17a

OTHER ID #

S

Enter the Florida Department of Health alphanumeric license number of the referring health care provider, if available.

17b

NPI #

N

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

S

Enter “FROM” and “TO” dates, in MMDDYY format, when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

S

Enter the word “ATTACHMENTS” If the claim form is accompanied by attachments(s) (e.g., documentation of supply costs, medical records, etc.).

20

OUTSIDE LAB?

N

CMS-1500 Box #

CMS-1500 (02/12) Field Description

Florida Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Florida Workers' Compensation Instructions

21

ICD IND.

R

Enter the applicable ICD indicator to identify which version of ICD codes are being reported:

9=ICD-9

0=ICD-10.

NOTE: ICD-9 shall be used for dates of service prior to the 10/01/2015 federal implementation date for the use of the ICD-10. ICD-10 shall be used for dates of service on or after the 10/01/2015 federal implementation date.

(ICD-9 AND ICD-10 CODES CANNOT BE USED TOGETHER.)

21.A

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

Enter the ICD diagnosis code. When more than one diagnosis is identified and multiple ICD codes are used, the code representing the primary diagnosis must be listed first in field 21(A).

Enter additional diagnosis codes (ICD) in fields 21(A) through 21(L).

NOTE: ICD-9 shall be used for dates of service prior to the 10/01/2015 federal implementation date for the use of the ICD-10. ICD-10 shall be used for dates of service on or after the 10/01/2015 federal implementation date.

(ICD-9 AND ICD-10 CODES CANNOT BE USED TOGETHER.)

21.B

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.C

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.D

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.E

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.F

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.G

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.H

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.I

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.J

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.K

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.L

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

22

RESUBMISSION CODE

S

This field is required if the bill is not an initial bill.

7= Replacement of prior claim

8= Cancellation or void of prior claim

23

PRIOR AUTHORIZATION NUMBER

S

Completion of this field is optional. Provider may enter the insurer/carrier’s prior authorization number, if available.

24A

DATE(S) OF SERVICE

R

Claim detail line. Enter the “FROM” and “TO” date of service in MMDDYY format. Multiple dates of service may be billed on a single line ONLY if the dates of service are consecutive and occur within the same month.

For example: April 30, May 1, 2, and 3, 2004

Line 1=043004

Line 2=050104 050304

If only a single date is applicable, enter the same date in the “FROM” and “TO” fields.

24B

PLACE OF SERVICE

R

Claim detail line. Enter the appropriate 2-digit numeric place of service code as identified in the Current Procedural Terminology (CPT) Manual.

24C

EMG

R

Claim detail line. Enter a “Y” for yes or “N” for no in this field to indicate if emergency care was provided.

24D

PROCEDURES, SERVICES, OR SUPPLIES

R

Claim detail line. Enter the valid CPT, CDT, HCPCS or unique workers’ compensation procedure code in the first section of Field 24D (under CPT/HCPCS). Enter “DSPNS” for each line item for which an NDC number(s) is listed in the shaded area of Field 24. Enter “COMPD” if the prescription dispensed is compounded by the physician and not commercially available. When required or appropriate, enter a 2- character modifier in the second section of Field 24D (under MODIFIER). See Rule 69L7.730(2), F.A.C., special billing instructions for anesthesia services.

NOTE: THE INSURER/CLAIM ADMINISTRATOR MUST NOT CHANGE OR MARK THROUGH THE ORIGINAL PROCEDURE CODE OR MODIFIER AS ENTERED BY THE HEALTH CARE PROVIDER.

24E

DIAGNOSIS CODE POINTER

R

Claim detail line. Enter the diagnosis reference letter(s) (A through L) from Field 21 to relate the date of service and procedures performed to the appropriate diagnosis. Up to four reference codes may be entered for each procedure code, as appropriate. Example: ABCD, KL, BDG

24F

$ CHARGES

R

Claim detail line. Enter the health care provider’s usual charge, in dollar and cent format, for the procedure reported on each line when a procedure code is entered in Field 24D. If multiple units are billed, enter the total charge by multiplying the units of service times the charge per unit.

NOTE: THE INSURER/CLAIM ADMINISTRATOR MUST NOT CHANGE OR MARK THROUGH THE CHARGE AMOUNT ENTERED BY THE HEALTH CARE PROVIDER.

24G

DAYS OR UNITS

R

Claim detail line. Enter the number(s) in Field 24G to represent the total number of units of services/supplies rendered. Enter all units of service that specify time in hours and quarter hours.

For example, if the time required were two hours and fifteen minutes, the entry on the claim form would be 2.25 units; one hour would be entered as 1 unit, etc.

24H

EPSDT/FAMILY PLAN

N

24I Grey

ID QUAL

N

24J Grey

RENDERING PROVIDER ID. #

N

24J

NPI#

N

24 Grey

GREY AREA SUPPLEMENTAL DATA

S

Required if procedure code in field 24D is DSPNS. When the dispensed medication is NOT repackaged/relabeled medication, enter the 11 digit Original NDC Number (5 4 2 format) preceded by the alpha-numeric qualifier “N4” in the shaded area of Field 24.

When the dispensed drug is a repackaged/relabeled drug, report the information in the shaded area of 24 in the following order: the alpha-numeric qualifier “N4”, 11-digit Repackaged NDC Number (5 4 2 format), “ORIG”, qualifier “N4”, 11-digit Original NDC Number (5 4 2 format).

25

FEDERAL TAX ID. NUMBER

R

Enter the tax identification number of the health care provider or entity to which payment is due. Enter an “x” in the appropriate box to indicate if the number is a Federal Employer Identification Number (FEIN) or a social security number SSN). Do not use special characters, e.g. periods (.), dashes (-), etc.

26

PATIENT'S ACCOUNT NO.

O

Completion of this field is optional. If completed, enter the injured employee’s account number as recorded in the health care provider’s accounting system.

27

ACCEPT ASSIGNMENT?

N

28

TOTAL CHARGE

R

Enter the total of all charges listed in field 24F using dollar and cent format. Do not use special characters, i.e., dollar signs ($) or decimal points(.) when reporting charges. Total each page separately if multiple Form DFS-F5-DWC9 (CMS-1500) claim forms are submitted for the same injured employee for the same date of service.

29

AMOUNT PAID

N

30

RSVD FOR NUCC USE

N

31

SIGNATURE OF PHYSICIAN OR SUPPLIER

R

Enter the name of the health care provider or entity that rendered the direct billable services.

THE HEALTH CARE PROVIDER’S NAME AND PERSONAL IDENTIFICATION NUMBER (FIELD 33 b) MUST AGREE.

32

SERVICE FACILITY LOCATION INFORMATION

R

Enter the zip code of the physical location where services were rendered.

32a

NPI #

N

32b

OTHER ID #

N

33

BILLING PROVIDER INFO & PH #

R

Enter the name, address including suite number and zip code of where payment shall be made for services provided by the practitioner listed in Field 33b.

33a

NPI #

N

33b

OTHER ID #

R

Enter the professional license number of the health care provider, who is authorized to bill directly for billable services rendered pursuant to Rule 69L- 7.730(2), F.A.C.).

Independent laboratories shall enter its alphanumeric state license number preceded by IL” (i.e. IL8##########);

Advanced Registered Nurse Practitioners enter “ARNP” for required alpha characters followed by a maximum of 9 numeric characters “ARNP#########”;

Radiology and Other Facilities (providing only the technical component) shall enter “XX99999999999”

Out-of State providers shall enter the WC unique license number “ZZ99999999999”.