1

Insurance program identification

Check only the type of health coverage applicable to the claim. This field indicated the payer to whom the claim is being field. Enter "X" in the box noted "Other"

1a

Insured identification (ID) number

The nine-digit identification number on the member's ID card

2

Patient's name (Last name, first name, middle initial)

Enter the patient's name as it appears on the member's ID. card. Do not use nicknames

3

Patient's birth date and sex

Enter the patient's eight-digit date of birth (MM/DD/YYYY), and mark the appropriate box to indicate the patient's sex/gender.

M= Male or F= Female

4

Insured's name

Enter the subscriber's name as it appears on the member's ID card

5

Patient's address (number, street, city, state, ZIP code) Telephone number (include area code)

Enter the patient's complete address and telephone number, including area code on the appropriate line.

First line - Enter the street address. Do not use commas, periods, or other punctuation in the address such as 123 N Main Street 101 instead of 123 N. Main Street, #101).

Second line - In the designated block, enter the city and state.

Third line - Enter the ZIP code and telephone number. When entering a nine-digit ZIP code (ZIP +4 codes), include the hyphen. Do not use a hyphen or space as a separator within the telephone number such as (803)5551414.

Note: Patient's telephone does not exist in the electronic 837 Professional 4010A1

6

Patient's relationship to insured

Always mark to indicate self if the same

7

Insured's address

(number, street, city, state, ZIP code) Telephone number (include area code)

Enter the insured's complete address and telephone number, including area code on the appropriate line.

First line - Enter the street address. Do not use commas, periods, or other punctuation in the address such as 123 N Main Street 101 instead of 123 N. Main Street, #101.

Second line - In the designated block, enter the city and state.

Third line - Enter the ZIP code and telephone number.

When entering a nine-digit zip code (ZIP + 4 codes), include the hyphen. Do not use a hyphen or space as a separator within the telephone number such as (803)5551414.

Note: Patient's telephone does not exist in the electronic 837 Professional 4010A1

8

Reserved for NUCC

N/A

9

Other insured's name (last name, first name, middle initial)

Refers to someone other than the patient. REQUIRED if patient is covered by another insurance plan. Enter the complete name of the insured

9a

Other insured's policy or group number

REQUIRED if field 9 is completed. Enter the policy of group number of the other insurance plan

9b

Reserved for NUCC

N/A

9c

Reserved for NUCC

N/A

9d

Insurance plan name or program name

REQUIRED if field 9 is completed. Enter the other insured's (name of person listed in field 9) insurance plan or program name

10 a, b, c

Is patient's condition related to:

Enter a Yes or No for each category/line (a, b and c). Do not enter a Yes and No in the same category/line. When marked Yes, primary insurance information must then be shown in box 11

10d

Claims codes (designated by NUCC)

When reporting more than one code, enter three blank spaces and then the next code

11

Insured policy or FECA number

REQUIRED when other insurance is available. Enter the policy, group, or FECA number of the other insurance. If box 10 a, b or c is marked Y, this field should be populated

11a

Insured date of birth and sex

Enter the eight-digit date of birth (MM/DD/YYYY) of the insured and an X to indicate the sex (gender) of the insured. Only one box can be marked. If gender is unknown, leave blank

11b

Other claims ID (Designated by NUCC)

The following qualifier and accompanying identifier has been designated for use:

Y4 Property Casualty Claim Number

For worker's compensation of property and casualty: Required if known.

Enter the claim number assigned by the payer

11c

Insurance plan name or program number

Enter name of the insurance health plan or program

11d

Is there another health benefit plan

Mark Yes or No. If Yes, complete field's 9a-d and 11c

12

Patient's or authorized person's signature

Enter "Signature on File," "SOF," or the actual legal signature. The provider must have the member's or legal guardian's signature on file or obtain his/her legal signature in this box for the release of information necessary to process and/or adjudicate the claim

13

Insured's or authorized person's signature

Obtain signature if appropriate.

14

Date of current:

Illness (First symptom) or

Injury (Accident) or

Pregnancy (LMP)

Enter the six-digit (MM/DD/YY) or eight-digit

(MM/DD/YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date.

Enter the applicable qualifier to identify which date is being reported.

431 Onset of Current Symptoms or Illness

484 Last Menstrual Period

15

If patient has same or similar illness. Give first date.

Enter another date related to the patient's condition or treatment. Enter the date in the six-digit

(MM/DD/YY) or eight-digit (MM/DD/YYYY) format

16

Dates patient unable to work in current occupation

Enter the six-digit (MM/DD/YY) or eight-digit (MM/DD/YYYY)

17

Name of referring physician or other source

Enter the name of the referring physician or professional (first name, middle initial, last name, and credentials)

17a

ID number of referring physician

Required if field 17 is completed. Use ZZ qualifier for Taxonomy code

17b

NPI number of referring physician

Required if field 17 is completed. If unable to obtain referring NPI, servicing NPI may be used

18

Hospitalization on dates related to current services

19

Reserved for local use - new form: Additional claim information

20

Outside lab/ charges

21

Diagnosis or nature of illness or injury (related items A-L to item 24E by line). New form allows up to 12 diagnoses, and ICD indicator

Enter the codes to identify the patient's diagnosis and/or condition. List no more than 12 ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field. Note: Claims missing or with invalid diagnosis codes will be rejected or denied for payment

22

Resubmission code /original REF

For resubmissions or adjustments, enter the original claim number of the original claim. New form - for resubmissions only:

- Replacement of Prior Claim

- Void/Cancel Prior Claim

23

Prior authorization number or CLIA number

Enter the authorization or referral number. Refer to the provider operations manual for information on services requiring referral and/or prior authorization.

CLIA number for CLIA waived or CLIA certified laboratory services

24 A-G Shaded

Supplemental information

The shaded top portion of each service claim line is used to report supplemental information for:

• NDC
• Narrative description of unspecified codes
• Contract rate
• For detailed instructions and qualifiers refer to Appendix IV of this guide

24A Unshaded

Dates of service

Enter the date the service listed in field 24D was performed (MM/DD/YYYY). If there is only one date, enter that date in the "From" field. The "To" field may be left blank or populated with the "From" date. If identical services (identical CPT/HCPC code(s)) were performed, each date must be entered on a separate line

24B Unshaded

Place of service

Enter the appropriate two-digit CMS standard place of service (POS) code. A list of current POS codes may be found on the CMS website

24C Unshaded

EMG

Enter Y (Yes) or N (No) to indicate if the service was an emergency

24D Unshaded

Procedures, services or supplies CPT/HCPCS modifier

Enter the five-digit CPT or HCPCS code and two-character modifier, if applicable. Only one CPT or HCPCS and up to four modifiers may be entered per claim line.

Codes entered must be valid for date of service.

Missing or invalid codes will be denied for payment.

Only the first modifier entered is used for pricing the claim. Failure to use modifiers in the correct position or combination with the procedure code, or invalid use of modifiers, will result in a rejected, denied, or incorrectly paid claim

24 E Unshaded

Diagnosis code

In 24E, enter the diagnosis code reference letter (pointer) as shown in box 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in box 21 only. Do not enter them in 24E. Do not use commas between the diagnosis pointer numbers. Diagnosis Codes must be valid ICD-10 codes for the date of service, or the claim will be rejected/denied

24 F Unshaded

Charges

Enter the charge amount for the claim line item service billed. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e. 10.00), enter 00 in the area to the right of the vertical line

24 G Unshaded

Days or units

Enter quantity (days, visits, units). If only one service provided, enter a numeric value of one

24 H Shaded

EPSDT (Family Planning)

Leave blank or enter "Y" if the services were performed as a result of an EPSDT referral

24 H Unshaded

EPSDT (Family Planning)

Enter the appropriate qualifier for EPSDT visit

24 I Shaded

ID qualifier

Use ZZ qualifier for taxonomy. Use 1D qualifier for ID, if an atypical provider

24 J Shaded

Non-NPI provider ID#

Typical providers: Enter the provider taxonomy code that corresponds to the qualifier entered in box 24I shaded. Use ZZ qualifier for taxonomy code

Atypical providers: Enter the provider ID number.

24 J Unshaded

NPI provider

ID

Typical providers ONLY: Enter the 10-character NPI of the provider who rendered services. If the provider is billing as a member of a group, the rendering individual provider's 10-character NPI may be entered. Enter the billing NPI if services are not provided by an individual (such as DME, independent lab, home health, RHC/FQHC general medical exam)

25

Federal Tax ID number SSN/EIN

Enter the provider or supplier nine-digit federal tax ID number, and mark the box labeled EIN

26

Patient's account NO

Enter the provider's billing account number

27

Accept Assignment?

Enter an X in the YES box. Submission of a claim for reimbursement of services provided to a recipient using state funds indicates the provider accepts assignment. Refer to the back of the CMS- 1500 (02-12) claim form for the section pertaining to payments

28

Total charge

Enter the total charges for all claim line items billed - claim lines 24F. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199999.99). Do not use commas. Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e., 10.00), enter 00 in the area to the right of the vertical line.

29

Amount paid

REQUIRED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing.

Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199999.99). Do not use commas. Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e., 10.00), enter 00 in the area to the right of the vertical line

30

Balance due

REQUIRED when field 29 is completed. Enter the balance due (total charges minus the amount of payment received from the primary payer).

Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199999.99). Do not use commas. Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e., 10.00), enter 00 in the area to the right of the vertical line

31

Signature of physician or supplier including degrees or credentials

If there is a signature waiver on file, you may stamp, print, or computer-generate the signature; otherwise, the practitioner or practitioner's authorized representative MUST sign the form. If signature is missing or invalid, the claim will be returned unprocessed.

Note: Does not exist in the electronic 837P

32

Service facility location information

REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

Enter the name and physical location. (PO box numbers are not acceptable here.)

First line - Enter the business/facility/practice name.

Second line- Enter the street address. Do not use commas, periods, or other punctuation in the address (for example, 123 N Main Street 101 instead of 123 N. Main Street, #101).

Third line - In the designated block, enter the city and state.

Fourth line - Enter the ZIP code and telephone number. When entering a nine-digit ZIP code (ZIP + 4 codes), include the hyphen

32a

NPI - Services rendered

Typical providers ONLY: REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

Enter the 10-character NPI of the facility where services were rendered.

32b

Other provider ID

REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

Typical providers: Enter the 2-character qualifier ZZ followed by the taxonomy code (no spaces).

Atypical providers: Enter the 2-character qualifier 1D (no spaces)

33

Billing provider INFO & PH#

Enter the billing provider's complete name, address (include the ZIP + 4 code), and telephone number.

First line -Enter the business/facility/practice name.

Second line - Enter the street address. Do not use commas, periods, or other punctuation in the address (for example, 123 N Main Street 101 instead of 123 N. Main Street, #101).

Third line - In the designated block, enter the city and state.

Fourth line- Enter the ZIP code and telephone number. When entering a nine-digit ZIP code (ZIP + 4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e., (555)555-5555).

NOTE: The nine digit ZIP code (ZIP + 4 code) is a requirement for paper and EDI claim submission

33a

Group billing NPI

Typical providers ONLY: REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

Enter the 10-character NPI .

33b

Group billing other ID

Enter as designated below the billing group taxonomy code.

Typical providers: Enter the provider taxonomy code. Use ZZ qualifier.

Atypical providers: Enter the provider ID number