Chapter 9
Completion of the HCFA-1500 Claim Form

9.1 Overview

ALL PAPER CLAIMS YOU SUBMIT ON BEHALF OF YOUR MEDICARE PATIENTS MUST BE SUBMITTED USING THE HCFA-1500 (12-90) CLAIM FORM. The only exception is ambulance claims which should continue to be submitted on the HCFA 1491 claim form. The HCFA-1500 (12-90) claim form is furnished to you printed in red ink. This is the only format that is accepted. Photocopies or xerox copies of the form will not be processed.

Medicare will not accept non-standard claims. Non-standard claims (i.e. "Superbills") can be defined as claims with extraneous attachments that are submitted by providers of service and (or) suppliers in lieu of entering the required information in the designated blocks on the HCFA-1500 (12-90) claim form. Claim attachments will be accepted only for information and evidence that cannot be readily entered in designated blocks of the standard claim form (i.e. medical records, certificates of medical necessity, other certifications or claim attachments required by law, regulations, or HCFA instructions).

The conditions which constitute a complete, valid claim have been standardized. Please refer to Section 9.3, Completion of the HCFA-1500 (12-90) claim form, for instructions on completing your Medicare Part B claims. All blocks on the claim form must be completed unless otherwise noted. These are defined as "required" or "mandatory." Those blocks noted as "conditional" must be completed for specific situations as noted within the block description. Any claim which is considered incomplete or invalid, due to missing HCFA-1500 (12-90) claim form data elements, will be rejected as "unprocessable".

9.2 Ordering HCFA-1500 (12-90) Claim Forms

The form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The HCFA-1500 (12-90) claim form may be purchased from local printers or through the following organizations:

U. S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
(202) 512-1800 (Pricing Desk)
FAX# (202) 512-2250
or
Order Department
AMA
P.O. Box 109050
Chicago, IL 60610-9050
American Express, Visa and Master Card orders
may be placed by calling 1-800-621-8335

9.3 Completion of the HCFA-1500 (12-90) Claim Form

a. Completing the HCFA-1500 (12-90) Claim Form

The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims. The top right margin of the claim form should NOT contain:

Please print legibly or type all information. Claims may also be computer-prepared.


BLOCK 1

Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.

Completion of this field is required for all claims.

BLOCK 1A INSURED'S I.D. NUMBER (For Program in Block 1)

Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.

Completion of this field is required for all claims.

BLOCK 2 PATIENT'S NAME

Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.

Completion of this field is required for all claims.

BLOCK 3 PATIENT'S BIRTH DATE AND SEX

Enter the patient's birth date (MMDDCCYY) and sex.

Completion of this field is required for all claims.

BLOCK 4 INSURED'S NAME

If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word "SAME". If there is no insurance primary to Medicare, leave blank.

Completion of this field is conditional for insurance information.

Graphic of Blocks 2, 3 and 4

BLOCK 5 PATIENT'S ADDRESS

Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.

Completion of this field is required for all claims; address and telephone must be indicated.

BLOCK 6 PATIENT RELATIONSHIP TO INSURED

Check the appropriate box for patient's relationship to the insured when block 4 is completed.

Completion of this field is conditional for insurance information when block 4 is completed.

BLOCK 7 INSURED'S ADDRESS

Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this block only when blocks 4 and 11 are completed.

Completion of this field is conditional for insurance information when blocks 4 and 11 are completed.

BLOCK 8 PATIENT STATUS

Check the appropriate box for the patient's marital status and whether employed or a student.

Graphic of Blocks 5 through 8

BLOCK 9 OTHER INSURED'S NAME

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank.

Participating providers of service and (or) suppliers must enter information required in block 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer.


Definitions: Medigap - A Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in 1882(g) (1) of Title XVIII of the Social Security Act and the definition contained in the NAIC Model Regulation which is incorporated by reference in the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the application of deductibles, coinsurance amounts or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.
Do not list other supplemental coverage in block 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. When there is no such contract, the beneficiary must file his/her own supplemental claim.

Completion of this field is conditional for insurance information related to Medigap.

BLOCK 9A OTHER INSURED'S POLICY OR GROUP NUMBER

Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.

BLOCK 9B OTHER INSURED'S DATE OF BIRTH

Enter the Medigap enrollee's birth date (MMDDCCYY) and sex.

BLOCK 9C EMPLOYER'S NAME OR SCHOOL NAME

Disregard "employer's name or school name" which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured's Medigap identification card. For example:

1257 Anywhere Street
Baltimore, MD 21204

is shown as "1257 Anywhere St MD 21204."

Note: If a carrier assigned unique identifier of a Medigap insurer appears in block 9D, block 9C may be left blank.

BLOCK 9D INSURANCE PLAN NAME OR PROGRAM NAME

Enter the name of the Medigap insured's insurance company or the Medigap insurer's unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in block 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.

Completion of fields 9A-D are conditional for insurance information related to Medigap.

BLOCK 10A THROUGH 10C IS PATIENT'S CONDITION RELATED TO:

Check "YES" or "NO" to indicate whether employment, auto accident or other accident (i.e., liability suit) involvement applies to one or more of the services described in block 24. Enter the state postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in block 11.

Completion of fields 10A-C are required for all claims; "Yes" or "No" must be indicated.

BLOCK 10D RESERVED FOR LOCAL USE

Use this block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by "MCD".

BLOCK 11 INSURED'S POLICY, GROUP OR FECA NUMBER

This block must be completed. By completing this block, the provider of service and (or) supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.

Note: If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to blocks 11a-11c.

If there is no insurance primary to Medicare, enter the word "NONE" in block 11 and proceed to block 12.

If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to block 11b.

Completion of block 11 (i.e., insured's policy/group number or "NONE") is required on all claims.

Completion of blocks 11B-C are conditional for insurance information primary to Medicare.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to another insurance include:

Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.

BLOCK 11A INSURED'S DATE OF BIRTH

Enter the insured's birth date (MMDDCCYY) and sex, if different from block 3.

BLOCK 11B EMPLOYER'S NAME OR SCHOOL NAME

Enter the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter the six - digit retirement date (MMDDYY) preceded by the word "RETIRED."

Completion of this field is conditional when the beneficiary has insurance primary to Medicare.

BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME

Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB.

Completion of this field is conditional for insurance information primary to Medicare.

BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN

Leave blank. Not required by Medicare.

BLOCK 12 PATIENT OR AUTHORIZED PERSON'S SIGNATURE

The patient or an authorized representative must sign and enter the six - digit date (MMDDYY) for this block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by: "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign the form. The signature on file authorization is effective indefinitely unless patient or the patient's representative revokes the arrangement.

The patient's signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.

Signature By Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.

Signature on File
Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary's behalf.

To utilize this procedure, the patient should sign a brief statement as follows:
(Name of Beneficiary) (Health Insurance Claim Number) 

"I request that payment of authorized Medicare benefits be made either to me 
or on my behalf to the name of provider of service and (or) supplier for any 
services furnished to me by that provider of service and (or) supplier. 
I authorize any holder of medical information about me to release to the 
Health Care Financing Administration and its agents any information 
needed to determine these benefits or the benefits payable for related service." 

(Beneficiary Signature) (Date)
Once the provider of service and (or) supplier has obtained the patient's one-time authorization, any later Medicare claims may be submitted by the provider of service and (or) supplier without obtaining any additional signature from the patient. When submitting claims, the statement "Signature on file" must be reflected in the patient's signature space (block 12) of the Health Insurance Claim Form.

When using this procedure, the provider of service and (or) supplier must:

1. Complete and submit the appropriate Medicare billing form for all services covered by the request for payment, even when the provider of service and (or) supplier has not accepted assignment.

2. Incorporate, by stamp or otherwise, on any bill sent to the beneficiary, information to the effect "Do not use this bill for claiming Medicare benefits. A claim has been or will be submitted to Medicare for you."

3. Cancel the authorization at the request of the patient.

4. Make the patient signature files available for carrier inspection upon request. (HGSAdministrators will conduct periodic audits of signature files on a random basis.) Completion of this field is required for all claims.

BLOCK 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Completion of this field is conditional for Medigap.

Note:   If you wish to report the statement "Signature on File" in block 13 in lieu of the patient's actual signature, the following statement must be signed by the patient and maintained in your records.

 
I request that payment of authorized Medigap benefits be made either to me or 
on my behalf to the provider of service and (or) supplier for any services furnished 
to me by that the provider of service and (or) supplier. I authorize any holder of 
Medicare information about me to release to (Name of Medigap Insurer) any 
information needed to determine these benefits payable for related services.

BLOCK 14 DATE OF CURRENT ILLNESS

Enter the six - digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six - digit date (MMDDYY) of the initiation of the course of treatment and enter the six - digit date (MMDDYY) x-ray date in block 19.

Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.

Completion of this field is required for all chiropractic services; conditional for other services.

BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

Leave blank. Not required by Medicare.

BLOCK 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

Enter the six - digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage.

Completion of this field is conditional for disability information.


BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.

Referring Physician - A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering Physician - A physician who orders nonphysician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.

All claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician's name and Unique Physician Identification Number (UPIN). This includes parenteral and enteral nutrition, immunosuppressive drugs, and the following:

Claims for other ordered/referred services not included in the preceding list must also show the ordering/referring physician's name and UPIN. For example, a surgeon must complete blocks 17 and 17A when a physician refers the patient. When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests), the performing physician's name and assigned UPIN must appear in blocks 17 and 17A.

All physicians must obtain a UPIN even though they may never bill Medicare directly. A physician who has not been assigned a UPIN must contact their Medicare carrier.

When a physician extender or other limited licensed practitioner refers a patient for a consultative service, the name and UPIN of the physician supervising the limited licensed practitioner must appear in blocks 17 and 17A.

When a patient is referred (e.g., for a consultative service) to a physician who also orders and performs a diagnostic service, a separate claim form is required for the diagnostic service.

Surrogate UPINs:If the ordering/referring physician has not been assigned a UPIN, one of the surrogate UPINs, described in block 17A, must be reported in block 17A. The surrogate UPIN used depends on the circumstances and is used only until the physician is assigned a UPIN. Enter the physician's name in block 17 and the surrogate UPIN in block 17A. All surrogate UPINs, with the exception of retired physician (RET000), are temporary and may be used only until a UPIN is assigned. Medicare carriers will monitor claims with surrogate UPINs.

Definitions:

Physician - the term "physician" means:
 - a doctor of medicine;
 - a doctor of osteopathy;
 - a doctor of dental surgery or of dental medicine;
 - a doctor of podiatric medicine;
 - a doctor of optometry; or
 - a doctor of chiropractic

Completion of this field is conditional for all ordered/referred services.

BLOCK 17A I.D. NUMBER OF REFERRING PHYSICIAN

Enter the HCFA assigned Unique Physician Identification Number (UPIN) of the referring or ordering physician listed in block 17. The first position of the UPIN must be alpha, the second and third alpha or numeric, and the last three, numeric.

When a claim involves multiple referring and/or ordering physicians, a separate HCFA 1500 (12-90) claim form must be used for each ordering/referring physician.

Use the following surrogate UPINs for physicians who have not been assigned individual UPINs. Claims received with surrogate numbers will be tracked and possibly audited.

Completion of this field is conditional for all ordered/referred services.

BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

Enter the six - digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Completion of this field is conditional for medical services related to hospitalization.

BLOCK 19 RESERVED FOR LOCAL USE

Enter the six - digit date (MMDDYY) the patient was last seen by the attending physician and the UPIN of his/her attending physician when an independent physical or occupational therapist, or physician providing routine foot care submits claims. For physical and occupational therapists, entering this information certifies that the required physician certification (or recertification) is being kept on file.

Chiropractic
Enter the six - digit date (MMDDYY) x-ray date for chiropractor services. By entering an x-ray date and the initiation date for course of chiropractic treatment in block 14, you are certifying that the relevant information requirements are on file (including the appropriate x-ray) and all are available for review.

Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.

Unlisted Drug Codes
Enter the drug's name and dosage when submitting a claim for a "not otherwise classified" (NOC) drugs.

Unlisted procedure code or not otherwise classified (NOC) codes
Enter a coherent description of an unlisted procedure code or not otherwise classified (NOC) code or a "not otherwise classified" (NOC) code if one can be given within the confines of this box. Otherwise an attachment must be submitted with the claim.

Modifier 99
Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in block 24d. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a modifier 99 should be listed as follows: 1= (mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.

Homebound
Enter the statement "Homebound" when an independent lab renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.

Assigned Benefits
Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim.

Hearing Aid
Enter the statement, "testing for hearing aid" when billing services involving the testing of a hearing aid is used to obtain intentional denials when other payers are involved.

Dental
When dental exams are billed, enter the specific surgery for which the exam is being performed.

Low Osmolar Contrast
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.

Post-Operative Care
Enter the six - digit assumed and/or relinquished date (MMDDYY) for a global surgery claim when providers share postoperative care.

Hospice
Enter the statement, "Attending physician, not hospice employee" when a physician renders services to a hospice patient but the hospice providing the patient's care (in which the patient resides) does not employ the attending physician.

Completion of this field is conditional as described above.

BLOCK 20 OUTSIDE LAB

Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the "YES" block is checked. A "YES" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "NO" check indicates that "no purchased tests are included on the claim". When "YES" is annotated, block 32 must be completed. When billing for multiple purchased diagnostic tests, each test must be submitted on a separate claim form.

Note: Do not report the ZP modifier with diagnostic services. If the technical portion of the diagnostic services was NOT purchased, block 20 should be checked "NO" . If the technical portion of the diagnostic service was purchased, blocks 20 and 32 of the HCFA-1500 claim form must be completed to meet purchased service criteria.

Completion of this field is conditional for diagnostic tests.

BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Enter the patient's diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.

All narrative diagnosis codes must be submitted on an attachment.

Graphic of Block 21Diagnosis Coding: Diagnosis codes are required on all physician claims.

The International Classification of Diseases, Clinical Modification (ICD-9-CM) is the coding system which must be used.

Note: See Chapter 1, section 1.12, for information on how to obtain an ICD-9-CM diagnosis code book.

Completion of this field is required for all physician services; conditional for non-physician services.

BLOCK 22 MEDICAID RESUBMISSION

Leave blank. Not required by Medicare.

BLOCK 23 PRIOR AUTHORIZATION NUMBER

Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.

Graphic of Block 23Enter the Investigational Device Exemption (IDE) number for those clinical trial procedures requiring IDE approval.

For physicians performing care plan oversight services, enter the six - digit Medicare provider number of the home health agency (HHA) or hospice when CPT code 99375 or 99376 or HCPCS code G0064, G0065, or G0066 is billed.

For paper claims only, enter the ten - digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.

Completion of this field is conditional the situations above

BLOCK 24A DATES OF SERVICE

Enter the six or eight - digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.

Completion of this field is required for all claims; all lines of service.

BLOCK 24B PLACE OF SERVICE

Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed. A complete list of the place of service definitions and their corresponding codes are listed below the chart.
Code

Service Location

Code

Service Location

11

Office

50

Federally Qualified Health Center

12

Home

51

Inpatient Psychiatric Facility

21

Inpatient Hospital

52

Psychiatric Facility Partial Hospitalization

22

Outpatient Hospital

53

Community Mental Health Center

23

Emergency Room - Hospital

54

Intermediate Care Facility/Mentally Retarded

24

Ambulatory Surgical Center

55

Residential Substance Abuse Treatment Facility

25

Birthing Center

56

Psychiatric Residential Treatment Center

26

Military Treatment Facility

60

Mass Immunization Center

31

Skilled Nursing Facility

61

Comprehensive Inpatient Rehabilitation Facility

32

Nursing Facility

62

Comprehensive Outpatient Rehabilitation Facility

33

Custodial Care Facility

65

End Stage Renal Disease Treatment Facility

34

Hospice

71

State or Local Public Health Clinic

41

Ambulance - Land

72

Rural Health Clinic

42

Ambulance - Air or Water

81

Independent Laboratory
   

99

Other Unlisted Facility
 
Note:  When a service is rendered to a hospital inpatient, use the "inpatient hospital" code.


Completion of this field is required for
all claims; all lines of service.

1. Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental facility;

2. 24 hour a day emergency care services;

3. Day treatment, other partial hospitalization services, or psychosocial rehabilitation services;

4. Screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission; and

5. Consultation and education services.

BLOCK 24C TYPE OF SERVICE

Not required by Medicare. Leave blank.

BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES

Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.

Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in block 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim.


BLOCK 24E DIAGNOSIS CODE

Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21.


Completion of this field is required for
all physician services; conditional for non-physician services.

BLOCK 24F ($) CHARGES

Enter the charge for each listed service.

Completion of this field is required for all claims (all lines of service).

BLOCK 24G DAYS OR UNITS

Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.

Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages or allergy testing procedures). When multiple services are provided, enter the actual number provided.

For anesthesia, show the elapsed time (minutes) in block 24G. Convert hours into minutes and enter the total minutes required for this procedure.

Suppliers must furnish the units of oxygen contents except for concentrators and initial rental claims for gas and liquid oxygen systems. Rounding of oxygen contents is as follows:

Completion of this field is required for all claims; (all lines of service).

BLOCK 24H EPSDT FAMILY PLANNING

Leave blank. Not required by Medicare.

BLOCK 24I EMG

Leave blank. Not required by Medicare.

BLOCK 24J COB

Leave blank. Not required by Medicare.

BLOCK 24K RESERVED FOR LOCAL USE

Enter the carrier assigned Provider Identification Number (PIN) with the three-digit group suffix when the performing provider of service and (or) supplier is a member of a group practice.

Note: Individual billing providers DO NOT use block 24k, refer to block 33.

Associations/Groups are assigned a three-digit suffix. These digits are formatted as one alpha and two alpha/numerics. This suffix is common to the group, and is used only to report the rendering physician number. The group will not report the suffix as part of the group number. All group members performing services for the group wil add this same suffix to his/her individual six-digit PIN.

When several different providers of service and (or) suppliers within a group are billing on the same HCFA 1500 (12-90) claim form, show the individual PIN with the three-digit suffix in the corresponding line item.

Completion of this field is conditional for members of a group practice.


BLOCK 25 FEDERAL TAX ID NUMBER

Enter your provider of service and (or) supplier Federal Tax Employer Identification Number (EIN) or Social Security Number. The participating provider of service and (or) supplier federal tax identification number is required for a mandated Medigap transfer.

Completion of this field is conditional for Medigap transfers.

BLOCK 26 PATIENT'S ACCOUNT NUMBER

Enter the patient's account number assigned by the provider of service and (or) supplier's accounting system. This is an optional field to enhance patient information.

BLOCK 27 ACCEPT ASSIGNMENT

Check the appropriate block to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in block 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.

Graphic of Blocks 25, 26, and 27The following provider of service and (or) supplier claims can only be paid on an assignment basis:

BLOCK 28 TOTAL CHARGE

Enter the total charges of all services reported on the claim (i.e., total of all charges from block 24f).

Completion of this field is required for all claims.

BLOCK 29 AMOUNT PAID

Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges.

Completion of this field (i.e., amount paid or "$0.00") is required for all claims.

BLOCK 30 BALANCE DUE

Leave blank. Not required by Medicare.

Graphic of Blocks 28, 29, 30

BLOCK 31 SIGNATURE OF THE PROVIDER OF SERVICE AND (OR) SUPPLIER INCLUDING DEGREE OR CREDENTIALS

Enter the signature of the provider of service and (or) supplier, or his representative, and the six - digit date (MMDDYY) the form was signed.

Completion of this field is required for all claims.

BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED

Enter the name and address of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient's home or physician's office. When the name and address of the facility where the services were furnished is the same as the biller's name and address shown in block 33, enter the word "SAME". Providers of service (namely physicians) must identify the supplier's name, address and carrier assigned Provider Identification Number (PIN) when billing for purchased diagnostic tests. When more than one supplier is used, a separate HCFA 1500 (12-90) claim form should be used to report and bill for each supplier.

This block is completed whether the supplier personnel performs the work at the physician's office or at another location.

If a QB or QU modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA), the physical location where the service was rendered must be entered if other than home. However, if the address shown in block 33 is in a HPSA and is the same as where the services were rendered, enter the word "SAME."

Graphic of Block 32If the supplier is a certified mammography center, enter the six-digit FDA certification number.

Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed and the carrier assigned PIN. If more than one outside laboratory was used, a separate HCFA-1500 (12-90) claim for must be completed for each supplier.

Completion of this field is conditional for the previously described reasons.

BLOCK 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER

Enter the physician's individual/group or or supplier's billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.

Individual Provider

Enter the carrier assigned PIN# preceded by the two alpha characters (Not the HCFA assigned UPIN) for the performing physician or supplier who is not a member of a group practice.

Group Practices

Enter the carrier assigned GRP# preceded by the 2-digit alpha characters. Complete either the PIN# or GRP# field, not both.

Completion of this field is required for all claims.

Graphic of Block 33

9.4 Join HCFA in Saving Medicare Trust Funds

The Health Care Financing Administration (HCFA) is continuing efforts to reduce costs and administrative waste. As of 4/1/96, a new editing process will be implemented for assigned claims which will save the Medicare Trust Fund millions of dollars. For some time, the denial of claims with incomplete or invalid information has resulted in claims surfacing inappropriately into the appeals process. This practice has not only been costly, it has resulted in an inappropriate use of the appeals system.

This new editing process will return paper or electronic claims to you as unprocessable if the claim contains certain incomplete or invalid information. No appeal rights will be afforded to these claims, or portion of these claims, because no "initial determination" can be made rendering the claim unprocessable.

This new editing process not only saves Medicare Trust Funds, there is little change and no additional administrative burdens for you. You will not be denied any services you are accustomed to. You will be able to correct an unprocessable claim under the new editing system with the same ease as you did under the current system. If you are accustomed to submitting corrections via the telephone, on a development letter, as a new claim, or in any format, that process will continue. However, you will not be granted a review because "returned" claims have no appeal rights.

One caution: Please correct "returned" claims promptly because only when that is done will you have met your legal obligation for submitting a Medicare claim. If you are a non-participating provider and currently bill beneficiaries prior to submitting a claim, you may continue to do so.

What does Return as Unprocessable mean?

Returning a claim as unprocessable does not mean your Medicare carrier will physically return every claim you submit with incomplete or invalid information. The term "return as unprocessable" is used to refer to the many processes utilized by your Medicare carrier today for notifying you that your claim cannot be processed, and that it must be corrected or resubmitted. Some (not all) of the various techniques for returning claims as unprocessable
include:

1. Incomplete or invalid information is detected at the front-end of your Medicare carrier's claims processing system. The claim is returned to you either electronically or in a hardcopy/checklist type form explaining errors and how to correct them.

2. Incomplete or invalid information is detected at the front-end of the claims processing system and is suspended and developed by your Medicare carrier. If corrections are submitted within a 45 day period, the claim is processed. Otherwise, the suspended portion is "returned as unprocessable" and you are notified by means of the remittance notice.

3. Incomplete or invalid information is detected within the claims processing system and is rejected through the remittance process by your Medicare Carrier. You are notified of any error(s) through the remittance notice, as well as how to correct it.

Note: An incomplete claim is a claim with missing, required information (e.g., no UPIN). An invalid claim is a claim that contains complete and necessary information; however, the information is illogical or incorrect (e.g., incorrect UPIN).

What information will be provided to assist you in correcting a claim?

To assist you in furnishing the appropriate corrections, the following information will be supplied (as long as it is on the received claim):

1) Beneficiary's name;
2) HIC number;
3) Dates of service;
4) Patient account or control number

An explanation of the errors will also be provided. This explanation will either be in the form of a description or a code. Exhibit III lists Reference Remark and MOA Codes.

Which Incomplete or Invalid Information will be Returned as Unprocessable?

The following information will be returned as unprocessable if it is not completed and/or entered accurately on the claim. Please note that a required data element must always be present on a claim (Refer to Exhibit I), a conditional data element must be present when certain condition(s) exist (Refer to Exhibit II).

To assist you in completing your claim:

Refer to Exhibit I and Exhibit II for details on fields or conditional information that will cause a claim to reject. For paper claims, refer to Chapter 9, section 9.3 of the Medicare Part B Reference Manual; for electronic claims, refer to the National Standard Format Specifications, Carrier National Standard Format Matrix Document, Medicare Part B Specifications for the ANSI X12 837, as well as Chapter 9. Please verify that your printing specifications are correct on a claim. Claims will be returned as unprocessable if the required information is submitted incorrectly.

Special Note: If you do not submit information for a required or conditional field(s) because the information is normally kept on file with your Medicare carrier, and can be supplied by your Medicare carrier, then the claim will not be returned as unprocessable. 

Exhibit II: List of Conditional Edits

Note:  Items from the HCFA-1500 form have been provided. These items are referred to as fields. Refer to Exhibit I which crosswalks HCFA-1500 items with records and fields on the National Standard Format.

Your claim will be returned or rejected as unprocessable:

1. If a service was ordered or referred by a physician (other than those services specified below) and the physician's name and/or UPIN (or surrogate) is not present in Fields 17 or 17A.

2. If a physician extender or other limited licensed practitioner refers a patient for consultative services, but the name and/or UPIN of the supervising physician is not entered in Fields 17 or 17A.

3. For diagnostic tests subject to purchase price limitations

4. If a diagnosis code listed in field 21 is missing, invalid or truncated or if the narrative diagnosis is not listed on an attachment.

5. If modifiers "QB" and "QU" are entered in Field 24D to refer to a Health Professional Shortage Area, but Field 32 is left blank, or contains no facility/laboratory name or carrier assigned PIN, or does not contain the word "SAME."

6. If a performing physician/supplier/or other practitioner is a member of a group practice and does not enter his or her carrier assigned Provider Identification Number (PIN) in Field 24K and the group number in Field 33.

7. If a primary insurer to Medicare is indicated in Field 11, but Fields 4, 6, and 7 are incomplete.

8. If there is insurance primary to Medicare that is indicated in Field 11 by either an insured/group policy number or the FECA number, but the insurance/program name in Field 11C is incomplete.

9. For chiropractor claims:

a. If the x-ray date(s) is not entered in Field 19.

b. If the initial date "actual" treatment began is not entered in Field 14.

Note: Record GCO, Field 5 of the NSF.

10. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and they do not enter the group's name or billing number in Field 33 and their personal PIN number in Field 24K. 

11. For durable medical, orthotic, and prosthetic claims, if the name or PIN of the location where the order was accepted is not entered in Field 32.

12. For physicians who maintain dialysis patients and receive a monthly capitation payment:

a. If the physician is a member of a professional corporation, similar group, or clinic, and the attending physician's PIN is not entered in Field 24K.

b. If the name or PIN of the facility involved with the patient's maintenance of care and training is not entered in Field 32.

13. For foot care claims, if the date the patient was last seen and the attending physician's UPIN are not present in Field 19.

14. For immunosuppressive drug claims, if a referring/ordering physician was used and their name and/or UPIN are not present in Fields 17 or 17A.

15. For all laboratory services, if the services of a referring/ ordering physician are used and his or her name and/or UPIN are not present in Fields 17 or 17A.

16. For laboratory services performed by participating hospital-leased laboratory or an independent laboratory (including services to a patient at home or in an institution), if the name or PIN of the laboratory where services were performed is not in Field 32.

17. For independent laboratory services involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if a prescribing physician does not validate any laboratory service(s) performed at home or in an institution by entering the appropriate annotation in Field 19 (i.e. - "Homebound").

18. For mammography "screening" and "diagnostic" claims, if a qualified screening center does not accurately enter their six-digit, FDA-approved facility identification number in Field 32 when billing the technical or global component.

19. For physician assistant, nurse practitioner, and clinical nurse specialist claims, if services are performed in a hospital setting but neither the hospital's name or PIN is entered accurately in Field 32.

20. For parenteral and enteral nutrition claims, if the services of an ordering/referring physician(s) are used and their name and/or UPIN is not present in Field 17 or 17A.

21. For portable X-Ray services claims, if the ordering physician's name and/or UPIN are not entered in Fields 17 or 17A.

22. For radiology and pathology claims for hospital inpatients, if the referring/ordering physician's name and/or UPIN (if appropriate) are not entered in Fields 17 or 17A.

23. For outpatient services provided by a qualified, independent physical or occupational therapist:

a. If the UPIN of the attending physician is not present in Field 19.

b. If the date the patient was last seen by the attending physician is not present in Field 19. 

24. If a HCPCS modifier must be associated with a HCPCS procedure code or if the HCPCS modifier is invalid.

If my claim is returned as unprocessable through the remittance notice, how will I be notified of the error(s)?

Medicare Inpatient Adjudication (MIA)/ Medicare Outpatient Adjudication (MOA)/Reference Remark Codes that will be used if your claim is returned as unprocessable through the remittance process. Please note that MIA/MOA Code MA130 will be present on the remittance notice for any claim returned for incomplete or invalid information.

Note: For a complete listing of Medicare Inpatient Adjudication (MIA)/Medicare Outpatient Adjudication (MOA/Reference Remark Codes, please reference chapter 21 on Standardization Codes.

a. Glossary of Terms

Incomplete Claim: A claim submitted with missing required information (i.e., - no provider number, no patient telephone number or at least 000-000-0000 for an unlisted telephone number).

Invalid Claim: A claim that contains complete and necessary information; however, the information is illogical or incorrect.

The following are a few examples of either an invalid or incomplete data element rejections:

Exhibit 1

1500 Claim Form

b. Appeal Rights

The law prohibits Medicare carriers to extend appeal rights for claims that contain incomplete or invalid information. No notice of appeal rights will be furnished in connection with the rejected claim because no "initial determination" on the claim was made. No beneficiary Explanation of Medicare Benefits (EOMB) will be issued for a rejected claim.

You cannot bill the beneficiary for the services; the claim must be corrected and resubmitted through the normal claim filing procedures.

c. Rejected Claims

If a claim is rejected, you will receive notification on your normal provider voucher or reconciliation file with the appropriate rejection information. It is your responsibility to verify that all information is complete before resubmitting the claim.

Note:  For EMC billers, all existing batch and claim level rejections will be retained. The PCLR 5001-5004 reports should be utilized for these rejections.

d. HCFA-1500 (12-90) Claim Form

If a claim is rejected for incomplete or invalid information, the service must be resubmitted. Please refer to Exhibit 1, the HCFA-1500 claim form for submission requirements chart. Do not submit a rejected service for a review. No written or telephone appeals will be offered. There will be no Explanation of Medicare Benefits (EOMB) forwarded to beneficiaries for a claim that HGSAdministrators' has determined to be "unprocessable".

The following is a description of the data element fields indicated on the example HCFA-1500 (12-90) claim form:

Required (R): Completion of this field is mandatory for all claims submitted to Medicare for processing.

Conditional (C): Completion of this field is dependent on various circumstances, as in the examples below:

1. If Medigap is involved, blocks 9, 9a, 9c, and 9d must be completed.

2. If non-physician services are ordered for a patient, the name and UPIN of the ordering physician must be entered in blocks 17 and 17a.

3. If diagnostic tests subject to purchase price limitations are reported, block 20 must be completed.

Optional (O): Completion of this field will not result in an incomplete or invalid claim rejection; however, we encourage you to fill in each block on a HCFA-1500 (12-90) claim form.

9.5 Mandatory Claim Submission

When Congress passed the Omnibus Budget Reconciliation Act of 1989, it included a requirement that all providers of service and (or) supplier submit complete/valid claims on behalf of Medicare beneficiaries for services furnished on or after September 1, 1990.  Congress believed this would yield more accurate information with which to evaluate  Medicare expenditures and other factors such as volume and intensity of services under the Medicare Volume Performance Standard (MVPS). The standard is Congress' primary tool for managing the growth in Medicare Part B expenditures for physician services.

a. Claims Filing Policy

Providers of service and (or) supplier must file with the Medicare carrier all claims for services and supplies provided to Medicare beneficiaries. The time limits for filing are as follows:

For Services Rendered Between:

Your Claim Must Be Submitted By:

Oct. 1,  1996 and Sept. 30, 1997

December 31, 1998

Oct. 1, 1997 and Sept. 30, 1998

December 31, 1999

Claims submitted outside of these time frames will be denied as untimely. Untimely claims may not be billed to the beneficiary.

Medicare assigned claims must be filed within one year from the service date or the payment will be reduced by 10%. The time limits for filing Medicare Part B claims are that the claim can be filed in the year the service was rendered; plus a year following the year for the service. Services rendered in the quarter from October through December are deemed rendered in the following year.

All paper Medicare claims must be submitted on the HCFA 1500 (12/90) claim form which is printed in red drop out ink.

For assigned claims processed on or after October 1, 1995, claims rejected due to incomplete/invalid claim data will require correction and resubmission by the provider.

For non-assigned claims processed on or after January 1, 1996, claims rejected due to incomplete/invalid claim data will require correction and resubmission by the provider regardless of the date of service.

The claims filing requirement applies to all providers of service and (or) supplier who provide services to Medicare beneficiaries. If a beneficiary requires a determination for a non-covered service, the provider of service and (or) supplier must submit the claim.

Providers of service and (or) supplier are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Provider of service and (or) supplier Program or the Medicare beneficiary is also a recipient of state Medical Assistance (Medicaid).

Providers of service and (or) supplier may not charge the beneficiary for preparing and filing a Medicare claim.

HGSAdministrators will monitor provider of service and (or) supplier compliance with the Medicare claims filing requirements.

Providers of service and (or) supplier who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation. 

b. Mandatory Claims Filing Does not Affect the Following:

Physician/Supplier/Beneficiary Payment Arrangements:Providers of service and (or) supplier who do not accept assignment may continue to request payment in full at the time that the service is provided. We encourage you to file the claims at the same time you request payment. This will reduce a potential financial hardship for the patient and reduce future inquiries to you about the status of the claim.

Non-Covered Medicare Services:Providers of service and (or) supplier must file claims on behalf of Medicare beneficiaries for non-covered services in order to get the information necessary to submit to other insurers upon the beneficiary's request.