CMS 1500

Billing instructions for the Division of Medical Assistance Programs

Overview

This presentation is intended to provide information to help those who bill the Division of Medical Assistance Programs (DMAP) for Medicaid services complete the billing form correctly the first time. This will give you step-by-step instructions so

DMAP can pay you, the provider, more quickly. This is to be used in conjunction with the General

Rules and your provider guidelines (rules and supplemental information). We hope you find this information useful.

This presentation only includes instructions for the 12/90 version of the CMS 1500.

About the CMS 1500

Ambulatory Surgical Centers

Certified Registered Nurse Anesthetists

Chemical Dependency Chiropractors Doctors of Medicine Durable Medical

Equipment Family Planning Clinics

Independent Laboratories Medical Transportation Mental Health Physical Therapy Podiatrists Psychologists School-Based Health

Services

The CMS 1500 is used for the following providers*:

This list does not include all provider types that use the CMS 1500. If in doubt of which claim form to use, refer to your provider guidelines, or contact DMAP Provider Services at 1-800-336-6016.

A few tips!

When submitting handwritten claim forms, use blue or black ink.

Make sure your handwriting is legible.

If possible, submit no more than six lines of services per claim form.

For multiple surgical procedures performed on the same day, bill on the same claim form.

Claims processing

The federal government requires DMAP to process Medicaid claims through an automated claim processing system known as MMIS - the Medicaid Management Information System. This system is a combination of people and

computers working together to process claims. This system performs daily edits for presence and

validity of data. DMAP staff only sees claims when the MMIS

cannot make a payment decision on a claim using the information submitted.

CMS 1500 form

DMAP does not supply this form.

It is available through: Local business forms suppliers. Oregon Medical Association. The U.S. Government Printing Office at

202-512-1800.

What version to use

Effective: October 2, 2006: DMAP will return to the provider

all claims submitted on the 8/05 form. Only use the 12/90 version.

January 2, 2007: DMAP will accept both the 12/90 and the 8/05 versions.

May 23, 2007: DMAP will only accept the 8/05 version. DMAP will return to the provider all claims submitted on the 12/90 form.

Introducing the CMS 1500

12/90 version

Red = Required Yellow = Optional

Top section

Enter the eight-character prime identification number.

Enter exactly as indicated on the Medical Care Identification.

1a. INSURED’S I.D. NUMBER

X X # # # X # X

Box 1a - Required

Enter the recipient name exactly as it is printed on the Medical Care Identification.

Use your patient’s last name first.

Do not use nicknames.

2. PATIENTS NAME (Last Name, First Name, Middle Initial)

PATIENT, YOUR

Box 2 - Required

If the recipient has other medical coverage, enter the appropriate two-digit third party resource (TPR) explanation code.

A code must be listed when the other insurance did not make a payment.

A code is always required when the recipient has more than one other insurance policy.

TPR codes can be found in your provider supplemental information.

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

NC

Box 9 - Optional

Check the appropriate box only when an injury is involved.

Do not check any boxes if there is no injury to report.

Box 10 - Optional

If the service normally requires prior authorization, but the service was provided in an emergency situation, enter a “Y” in this box.

Y

Box 10d - Optional

Red = Required Yellow = Optional

Middle section

Enter the six-digit DMAP provider number of the referring provider.

If the referring provider is not enrolled with DMAP, enter six nines (999999).

This box may be required if the patient has a Primary Care Manager. Refer to OAR 410-141-0410 for specifics.

17a. I.D. NUMBER OF REFERRING PHYSICIAN

999999

Box 17a - Optional

Enter the primary diagnosis/condition of the recipient by entering current ICD-9-CM codes.

The diagnosis code must be the reason chiefly responsible for the service being provided as shown in medical records.

You may enter up to four codes and they must be carried out to the highest degree of specificity.

Do not use the decimal point.

7993

Box 21 - Required

If the service was prior authorized, enter the nine-digit prior authorization number that DHS issued for the service.

Only use one prior authorization number per claim form.

Do not bill prior authorized and unauthorized services on the same claim form.

23. PRIOR AUTHORIZATION NUMBER

061300923

Box 23 - Optional

Red = Required Yellow = Optional

Bottom section

This box must list numeric dates of service.

If billing for one day, complete only the “from” column.

If the “from and to” dates are used, a service must be on consecutive days and provided no more than once per day.

10 01 06

10 03 06

10 07 06 10 09 06

Box 24A - Required

List the place of service code that indicates where the service was provided.

You may also use current two-digit CMS codes available in your CPT book.

3

3

3

Box 24B - Required

List the five-digit CPT or HCPCS code for the specific service provided.

For procedure codes that indicate “unlisted,” you must attach an operative/medical report.

List the two-digit national modifier that describes the service.

99213 - 25

99214

99214

Box 24D - Required

1

1

1

List the one-digit number that cross-references with the diagnosis code that is listed in box 21.

Do not enter the actual ICD-9-CM code here.

Box 24E - Required

Enter the total usual and customary charge for each line.

Do not list credits.

Do not use dashes.

DMAP will not calculate your charge if billing for more than 1 item (unit).

22 80

22 80

68 40

Box 24F - Required

1

1

3

Enter the number of units for each number of consecutive days or services as indicated in box 24A.

Some services are billed by units, depending on the service provided.

Box 24G - Required

List the six-digit DMAP performing provider number.

This box is required when group practices bill with their specific billing provider number in box 33.

Box 24K - Optional

26. PATIENT’S ACCOUNT NO.

112

Enter your patient account number here.

This box allows up to twelve characters.

This number will appear on your Remittance Advice (RA).

Box 26 - Optional

114 00 0 00 114 00

Box 28 - Enter the total amount for all charges listed in column 24F. Each claim form is a separate document, and is to be totaled as such.

Box 29 - Enter the total amount paid by any prior resource(s). Do not include write offs, how much DMAP previously paid, or copayments.

Box 30 - Enter the balance due. Box 28 minus box 29 must equal box 30.

Boxes 28-30 - Required

33. PHYSICIAN’S SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE #

Dr. Office PO Box ### Salem, OR 97305 PIN # GRP # ###### Enter your six-digit DMAP billing or performing provider

number. Payment will go to this provider.

List your name and address.

Box 33 - Required

PATIENT, YOUR

XX###X#X

NC

061300923

100106 3 99213-25

100306 3 99213

100606 100906 3 99214

22.80 1

22.80 1

68.40 3

112

Dr. Office PO Box ### Salem, OR 97305 ######

114.00 114.00

7993

999999

E

X

A

M

P

L

E

Red = Required

Yellow = Optional

1

1

1

Mail

Mail your CMS 1500 claim form to:

DMAP

PO Box 14955

Salem, OR 97309-4957

Need Help?

Contact DMAP Provider Services if you need assistance or have questions concerning your CMS 1500 claim form. Toll free 800-336-6016 Local 503-378-3697 Fax 503-945-6873 E-mail dmap.providerservices@state.or.us

Thank You!