PLEASE PRINT OR TYPE

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1 SAMPLE PLEASE PRINT OR TYPE APPROVED OMB FORM 1500 (02-12)

2 1500 Claim Frm Instructins Prviders must use the 1500 Claim Frm when requesting payment fr medical services and supplies prvided under the Kansas Medical Assistance Prgram (KMAP). Claims can be submitted n the KMAP secure website, as an electrnic 837 file, thrugh Prvider Electrnic Slutins (PES), r n an riginal, red ink 1500 paper claim frm versin 02/12. When a paper claim is submitted fr a KMAP beneficiary, KMAP must be indicated n the frm and the frm shuld be cmpleted using the instructins indicated belw. Claims nt meeting these submissin requirements will be returned t the prvider. KanCare (managed care) claims shuld be submitted t the apprpriate KanCare managed care rganizatin (MCO). The fiscal agent des nt furnish the paper 1500 Claim Frm t prviders. The frm must be btained frm a claim frm supplier, such as the nes listed belw. Administrative Services f Kansas, Inc. PO Bx 3500 Tpeka, KS Advantage Business Frms PO Bx Tpeka, KS TFP Data Systems , ext The Gvernment Printing Office Send cmpleted paper claim t: Kansas Medical Assistance Prgram Office f the Fiscal Agent PO Bx 3571 Tpeka, Kansas Fr additinal infrmatin regarding the apprved versin f the 1500 Claim Frm, refer t the Natinal Unifrm Claim Cmmittee (NUCC) website. Nte: Fr all paper claims, the Kansas MMIS uses electrnic imaging and ptical character recgnitin (OCR) equipment. Therefre, infrmatin will nt be recgnized if nt submitted in the crrect fields as instructed Claim Frm Instructins Page 1 f 9 Revised

3 1500 Claim Frm Instructins Billing Instructins The fllwing numbered fields are t be cmpleted when required r if applicable. NOTE: Fields with an * are nt required fr fee-fr-service Medicaid claims. Field 1 Field 1a Field 2 Field 3 PROGRAM IDENTIFICATION Check apprpriate bx(es). INSURED'S ID NUMBER Enter the 11-digit beneficiary ID number frm beneficiary's KMAP ID card. If newbrn services, use mther's beneficiary ID number if newbrn's number is unknwn. PATIENT'S NAME Enter the beneficiary's last name, first name, and middle initial exactly as it appears n the medical ID card. If the patient is a newbrn, enter newbrn, baby by, r baby girl, in the first name field and enter the last name. PATIENT'S DATE OF BIRTH Enter the beneficiary's date f birth as mnth, day, and year - MM/DD/YYYY (such as Octber 1, 1957 wuld be listed as 10/01/1957). If newbrn services, enter the baby's date f birth (nt the mther's). PATIENT'S SEX Check the apprpriate bx. Field 4* Field 5 Field 6* Field 7* Field 9 Field 10 INSURED S NAME Enter the beneficiary s full last name, first name, and middle initial. If the beneficiary uses a last name suffix (such as, Jr r Sr), enter it after the last name and befre the first name. Titles (such as, Sister, Capt, r Dr) and prfessinal suffixes (such as, PhD, MD, r Esq) shuld nt be included. PATIENT'S ADDRESS Enter the beneficiary's street address including city, state, and ZIP cde. PATIENT RELATIONSHIP TO INSURED Place an X in the crrespnding bx t indicate the patient s relatinship t insured when Field 4 is cmpleted. Only mark ne bx. INSURED S ADDRESS Enter the beneficiary s address. If Field 4 is cmpleted, then this field shuld be cmpleted by entering the street address including city, state, and ZIP cde. OTHER INSURED'S NAME If the beneficiary has secndary r supplemental insurance, cmplete Fields 9, 9a, and 9d. (Enter the primary insurance infrmatin in Field 11.) IS PATIENT'S CONDITION RELATED TO Check the apprpriate bx when billing fr accident-related services nly. If a bx is checked, enter all available infrmatin in Field Claim Frm Instructins Page 2 f 9 Revised

4 1500 Claim Frm Instructins Field 11 Field 12* Field 13 Field 14 Field 15* Field 16* Field 17 INSURED'S POLICY GROUP OR FECA NUMBER This field shuld be cmpleted if the beneficiary has insurance primary t Medicaid. If yes, cmplete Fields 11a-d. PATIENT S OR AUTHORIZED PERSON S SIGNATURE Enter Signature n file, SOF, r legal signature. If legal signature, enter the date signed in six-digit (MM/DD/YY) r eight-digit (MM/DD/YYYY) frmat. If there is nt a signature n file, leave blank r enter N signature n file. INSURED S OR AUTHORIZED PERSON S SIGNATURE Enter Signature n file, SOF, r legal signature. If there is nt a signature n file, leave blank r enter N signature n file. DATE OF CURRENT ILLNESS, INJURY, OR PREGNANCY (LMP) Enter the eight-digit date (MM/DD/YYYY) f the first date f the present illness, injury, r pregnancy. Fr pregnancy, use the date f the last menstrual perid (LMP) as the first date. Enter the applicable qualifier t identify which date is being reprted. 431 Onset f current symptms r illness 484 Last menstrual perid OTHER DATE Enter the date related t the patient s cnditin r treatment. Enter the date in an eight-digit date frmat (MM/DD/YYYY). Enter the applicable qualifier t identify which date is being reprted. 090 Reprt start (assumed care date) 091 Reprt end (relinquished care date) 304 Latest visit r cnsultatin 439 Accident 444 First visit r cnsultatin 453 Acute manifestatin f a chrnic cnditin 454 Initial treatment 455 Last X-ray 471 Prescriptin DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Enter a six-digit (MM/DD/YY) r eight-digit (MM/DD/YYYY) date in the frm-t dates area if the patient is emplyed and is unable t wrk in current ccupatin. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Enter the name f the referring, rdering, r supervising physician fr the fllwing types f claims: Thse filed by a cnsultant fr cnsultatin services Thse filed by labratry and radilgy services Thse filed by a prvider wh has rendered services t a lck-in beneficiary Enter the applicable qualifier t the left f the vertical, dtted line. DN Referring prvider DK Ordering prvider DQ Supervising prvider 1500 Claim Frm Instructins Page 3 f 9 Revised

5 1500 Claim Frm Instructins Claims (fr dates f service n and after April 1, 2015) billed by the fllwing prvider types must enter the name f the rdering r referring prvider. Nte: Fr hspice beneficiaries ONLY wh reside in a NF, ICF-IID, r hspital swing bed, enter the name f the facility in Field Hme Health Agency 17 Therapist 24 Pharmacy 25 DME/Medical Supply Dealer 28 Labratry 29 X-ray Clinic Nte: The rdering prvider name shuld be submitted if the claim cntains bth an rdering and referring prvider. Field 17a ID NUMBER OF REFERRING PHYSICIAN This field is used t capture the KMAP ID r taxnmy cde fr the referring, rdering, r supervising physician. The field shuld NOT be used if either: The referring, rdering, r supervising physician is required t use their Natinal Prvider Identifier (NPI) number. OR The referring, rdering, r supervising physician infrmatin is nt required t be sent. If the referring r rdering prvider des nt have an NPI number and is required t be reprted, use the fllwing qualifiers. Enter qualifier G2 (Prvider Cmmercial Number) and the 10-digit KMAP prvider ID f the referring r rdering physician. Enter all nines if the referring r rdering physician is nt a KMAP prvider. If the supervising prvider des nt have an NPI number and is required t be reprted, use the fllwing qualifiers. Enter qualifier LU (Lcatin Number) and the 10-digit KMAP prvider ID f the supervising physician Enter all nines if the supervising physician is nt a KMAP prvider. Nte: In accrdance with the NUCC manual, qualifier LU is used fr the supervising prvider nly. Field 17b PROVIDER S NPI Enter the HIPAA NPI f the referring, rdering, r supervising physician. Claims (with dates f service n and after April 1, 2015) billed by the fllwing prvider types must enter the NPI f the referring r rdering prvider n the claim. 05 Hme Health Agency 17 Therapist 24 Pharmacy 25 DME/Medical Supply Dealer 28 Labratry 29 X-ray Clinic Nte: The rdering prvider NPI shuld be submitted if the claim cntains bth an rdering and referring prvider Claim Frm Instructins Page 4 f 9 Revised

6 1500 Claim Frm Instructins Field 18 Field 19* Field 20 Field 21 Field 22 Field 23 Field 24 Field 24A Field 24B HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Enter dates f admissin and discharge. ADDITIONAL CLAIM INFORMATION If the field is required by the payer, enter the apprpriate qualifiers describing the identifier. D nt enter a space, hyphen, r ther separatr between the qualifier cde and number. OUTSIDE LAB Check apprpriate bx: If n, bill fr prcedures perfrmed. If yes, prvider wh actually perfrmed service must bill. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the apprpriate ICD cde. If mre than ne diagnsis applies, list the primary n Line A, secndary n Line B, etc. RESUBMISSION List the riginal reference number fr resubmitted claims. PRIOR AUTHORIZATION NUMBER Enter the assigned prir authrizatin (PA) number frm the apprval letter, when applicable. SUPPLEMENTAL INFORMATION Enter in the shaded areas f the numbered rws, as apprpriate. Narrative descriptin f unspecified cdes Natinal Drug Cdes (NDCs) fr drugs Cntract rate Tth numbers and areas f the ral cavity Fr cmplete infrmatin n supplemental items, reference the NUCC CMS 1500 Claim Frm Reference Instructin Manual n the NUCC website. DATE(S) OF SERVICE Enter the date f service in MM/DD/YY frmat. If multiple services were perfrmed n cnsecutive dates, put the beginning date in the Frm field and the last date f service in the T field and cmplete the Units field (24G) accrdingly. PLACE OF SERVICE Enter the apprpriate place f service (POS) cde fr each service. Nt all f the POS cdes may be apprpriate fr the service prvided. Indicate the POS cde that mst accurately reflects where the service was prvided. 11 Office 12 Hme 19 Off campus utpatient hspital 21 Inpatient hspital 22 On campus utpatient hspital 23 Emergency rm hspital 24 Ambulatry surgical center 31 Skilled nursing facility 1500 Claim Frm Instructins Page 5 f 9 Revised

7 1500 Claim Frm Instructins 32 Nursing facility 33 Custdial care facility 34 Hspice 41 Ambulance land 42 Ambulance air r water 50 Federally Qualified Health Center (FQHC) 53 CMHC 54 ICF/IID 65 End-stage renal disease treatment facility 71 Lcal health department 72 Rural Health Clinic (RHC) 81 Independent labratry 99 Other lcatins Field 24C* Field 24D Field 24E Field 24F Field 24G Field 24H EMG If this field is required by the payer, in the bttm, unshaded area, enter Y fr Yes r leave blank fr N. PROCEDURES, SERVICES, OR SUPPLIES Enter the HCPCS five-digit base prcedure cde (add mdifier[s] if apprpriate). Explain unusual circumstances. DIAGNOSIS CODE Enter the apprpriate line alpha character frm Field 21. CHARGES Enter yur usual and custmary charge fr each service. DAYS OR UNITS Enter the number f visits, days, r units f service rendered, as applicable t each detail line. FQHCs and RHCs shuld bill nly ne encunter per claim detail. EPSDT FAMILY PLAN COB: (EPSDT/KBH referral value) Enter the tw-digit value when an EPSDT (KBH) screen results in a referral. The value chices include: AV The beneficiary refused the referral. S2 The beneficiary is currently under treatment. ST New services requested. EPSDT / Family Planning: Enter E when cmpleting an EPSDT (KBH) screen. Enter F when cmpleting a family planning visit. Enter B when bth an EPSDT (KBH) and family planning visit are cmpleted. Field 24I ID QUALIFIER Enter qualifier G2 if billing with a KMAP prvider ID in the tp half f Field 24J. Enter qualifier PXC if billing with a taxnmy cde in the tp half f Field 24J Claim Frm Instructins Page 6 f 9 Revised

8 1500 Claim Frm Instructins Field 24J RENDERING PROVIDER ID # Enter in the tp half a 10-digit KMAP prvider ID r a taxnmy cde. Enter in the bttm half the prvider s NPI. Field 25* Field 26 Field 27 Field 28 Field 29 Field 31 FEDERAL TAX ID NUMBER Enter the federal tax ID number (emplyer ID number r SSN) f the billing prvider identified in Item Number 33. Place an X in the apprpriate bx t indicate which number is being reprted. Only ne bx can be marked. YOUR PATIENT'S ACCOUNT NUMBER OPTIONAL: Any alpha/numeric character entered in this field will be referenced n the remittance advice (RA). N unique characters shuld be indicated, such as -, r #. ACCEPT ASSIGNMENT Leave blank. All KMAP prviders must accept assignment in rder t receive payment n a Medicare-related claim. TOTAL CHARGE Enter the ttal f all the itemized charges n this page f the claim. (D nt include cpayment amunt. Refer t Sectin 8100 f each individual prvider manual.) When mre than ne claim page is used fr the same beneficiary, fr the same date f service, fllw the instructins belw: Ensure that multiple pages f the claims are sent t Medicaid tgether. D nt ttal the charges in Field 28 n each claim frm. Only ttal all itemized charges (n all claim frms) n the last claim page. Enter Cntinued. Page f in Field 28. Fr example, when 10 prcedures were prvided fr the same beneficiary n the same date f service enter Cntinued. Page 1 f 2. Enter the ttal charge in Field 28 f the last page f the claim frm. Accrding t the example abve, the ttal charge wuld be in Field 28 n Page 2. AMOUNT PAID Enter any amunt paid by insurance r ther third-party surces knwn at the time the claim is submitted n the last claim page submitted. If the amunt shwn in this field is the result f ther insurance, dcumentatin f the payment must be attached. (Field 11 must identify the ther insurance surce.) Refer t Sectins 3200 and 3300 f the General Third Party Liability Payment Prvider Manual fr mre specific infrmatin. D nt enter cpayment r spenddwn payment amunts. They are deducted autmatically. Nte: Retain prf f ther insurance payment in the beneficiary s file. SIGNATURE OF PHYSICIAN OR SUPPLIER Read the statement n the back f the claim frm, sign, and date. Phrase Signature n file is acceptable. Prvider s name typed r stamped is acceptable Claim Frm Instructins Page 7 f 9 Revised

9 1500 Claim Frm Instructins Field 32 SERVICE FACILITY LOCATION INFORMATION Enter the name, address, city, state, and ZIP cde f the lcatin where the services were rendered. Prviders f service (namely physicians) must identify the supplier s name, address, ZIP cde, and NPI number when billing fr purchased diagnstic tests. If the service facility lcatin is a cmpnent r subpart f the billing prvider and they have their wn NPI that is reprted n the claim, then the subpart is reprted as the Billing Prvider and Service Facility Lcatin is nt used. When reprting an NPI in the Service Facility Lcatin, the entity must be an external rganizatin t the billing prvider. Submissin f the lcatin where the service was rendered is required fr all POS cdes. When mre than ne supplier is used, a separate 1500 Claim Frm shuld be used t bill fr each supplier. Only ne name, address, and ZIP cde can be entered in the blck. Nte: The service facility lcatin address must be a street address r physical lcatin, nt a PO Bx. Field 32a Field 32b PROVIDER S NPI Enter the prvider s NPI. OTHER ID NUMBER SERVICE FACILITY Enter qualifier G2 and the 10-digit KMAP prvider ID r qualifier PXC and a taxnmy cde. Field 33 BILLING PROVIDER INFO & PH #: Enter the prvider s r supplier s billing name, address, ZIP cde, and phne number. The phne number is t be entered in the area t the right f the field title. Enter the name and address infrmatin in the fllwing frmat: 1 st Line Name 2 nd Line Address 3 rd Line City, State, and ZIP Cde Item 33 identifies the prvider that is requesting t be paid fr the services rendered and shuld always be cmpleted. D nt use punctuatin (i.e., cmmas, perids) r ther symbls in the address (e.g., 123 N Main Street 101 instead f 123 N. Main Street, #101). Enter a space between the twn name and state cde; d nt include a cmma. Reprt a nine-digit ZIP cde, including the hyphen. D nt use a hyphen r space as a separatr within the telephne number. If reprting a freign address, cntact the payer fr specific reprting instructins. Nte: The billing prvider address must be a street address r physical lcatin, nt a PO Bx. Field 33a PROVIDER S NPI Enter the prvider s NPI. If a paper claim is submitted directly t the fiscal agent, the NPI is required in this field. All prvider types and specialties must cmply with this requirement, except mst f prvider type 55 (HCBS). The fllwing HCBS (55) specialties must als cmply: 237 Targeted Case Management 514 Wellness Mnitring - FE 515 Nursing Evaluatin 1500 Claim Frm Instructins Page 8 f 9 Revised

10 1500 Claim Frm Instructins 517 Wellness Mnitring I/DD 521 Specialized Medical Care RN I/DD Specialized Medical Care LPN I/DD 532 Hme Telehealth 550 Autism Specialist 551 Intensive Individual Supprt - AU 553 Parent Supprt - AU 554 Family Adjustment Cunseling - AU 555 Case Management/Care Crdinatin - TA 560 Health Maintenance Mnitring 561 Intermittent Intensive Medical Care Field 33b KMAP PROVIDER ID OR TAXONOMY CODE Enter qualifier G2 and the 10-digit KMAP prvider ID r qualifier PXC and a taxnmy cde Claim Frm Instructins Page 9 f 9 Revised