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CMS-1500 (HCFA)

Applicable Services

Supporting Documentation

Forms & Attachments

Filling out the Form

Instructions

Service

Rule

Physician Services

RULE 099.30 (I)(4) MEDICAL COST CONTAINMENT PROGRAM

DME

Not specifically mentioned

Laboratory / Pathology

CMS-1500 Medical Bill

Required Supporting Documentation

By Report Codes

a. Operative report, or

b. Consultation report, or

c. Progress note, or

d. Office notes or other applicable documentation, or

e. Description of equipment or supply (when applicable)

DME

Copy of invoice, brand name, model number and/or catalog number

CMS-1500 Box #

CMS-1500 (02/12) Field Description

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

Arkansas Workers' Compensation Instructions

0

CARRIER NAME AND ADDRESS

1

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

1a

INSURED’S I.D. NUMBER

R

Insured's ID Number

2

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

R

Patient's Name

3

PATIENT’S BIRTH DATE, SEX

R

Patient's Date of Birth and Gender

4

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

R

Employer's Name

5

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

R

Patient's Address

6

PATIENT RELATIONSHIP TO INSURED

R

Patient's Relationship to Subscriber

7

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

R

Employer's Address

8

RESERVED FOR NUCC USE

9

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

9a

OTHER INSURED'S POLICY OR GROUP NUMBER

9b

RESERVED FOR NUCC USE

9c

RESERVED FOR NUCC USE

9d

INSURANCE PLAN NAME OR PROGRAM NAME

10a

IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT

10b

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

10c

IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT

10d

CLAIM CODES (Designated by NUCC)

CMS-1500 Box #

CMS-1500 (02/12) Field Description

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

Arkansas Workers' Compensation Instructions

11

INSURED'S POLICY GROUP OR FECA NUMBER

S

Worker's Comp Claim number assigned by Insurance Carrier. If not known, billig provider shall enter "Unknown."

11a

INSURED'S DATE OF BIRTH, SEX

11b

OTHER CLAIM ID (Designated by NUCC)

11c

INSURANCE PLAN NAME OR PROGRAM NAME

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

14

DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)

R

Date of Injury

15

OTHER DATE

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE

S

Required when another healh care provider referred the patient for the services

17a

OTHER ID #

17b

NPI #

S

Required when CMS-1500/Field 17 contains the name of a healh care provider eligible to receive an NPI number.

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

20

OUTSIDE LAB?

CMS-1500 Box #

CMS-1500 (02/12) Field Description

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

Arkansas Workers' Compensation Instructions

21

ICD IND.

R

At least one diagnosis must be present

21.A

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

S

21.B

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

S

21.C

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

S

21.D

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

S

21.E

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

S

21.F

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

S

21.G

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

S

21.H

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

S

21.I

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

S

21.J

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

S

21.K

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

S

21.L

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

S

22

RESUBMISSION CODE

23

PRIOR AUTHORIZATION NUMBER

S

Required when available

24A

DATE(S) OF SERVICE

R

Date of service

24B

PLACE OF SERVICE

R

Place of service

24C

EMG

24D

PROCEDURES, SERVICES, OR SUPPLIES

R

Procedure/Modifier Code

24E

DIAGNOSIS CODE POINTER

R

Diagnosis Pointer

24F

$ CHARGES

R

Charges for each listed service

24G

DAYS OR UNITS

R

Number of days or Units

24H

EPSDT/FAMILY PLAN

24I Grey

ID QUAL

24J Grey

RENDERING PROVIDER ID. #

24J

NPI#

S

Rendering provider's NPI number. Required when rendering provider is eligible for an NPI number.

24 Grey

GREY AREA SUPPLEMENTAL DATA

25

FEDERAL TAX ID. NUMBER

R

Billing provider's Federal Tax ID Number

26

PATIENT'S ACCOUNT NO.

27

ACCEPT ASSIGNMENT?

28

TOTAL CHARGE

R

Required, but when claim has multiple pages the grand total may be submitted on the last page and the phrase "next page' may be submitted on all other pages.

29

AMOUNT PAID

30

RSVD FOR NUCC USE

31

SIGNATURE OF PHYSICIAN OR SUPPLIER

R

Signature of Physician or Supplier, the degrees or credentials and the date. Required, but may be represented as "signature on file" and the typed name of physician or supplier.

32

SERVICE FACILITY LOCATION INFORMATION

R

Service facility location information

32a

NPI #

S

Required when facility is eligible for an NPI numberBil

32b

OTHER ID #

33

BILLING PROVIDER INFO & PH #

R

Billing provider's name, address and telephone number.

33a

NPI #

S

Billing provider's NPI number, when billing provider is elble for an NPI number

33b

OTHER ID #