Claim Form Billing Instructions CMS-1500 (08-05) Claim Form Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 1 of 10
Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 2 of 10
Item Number Required Field? Description and Instructions 1 Optional Enter an X in the appropriate box to indicate the health insurance applicable to this claim. 1 a Required Insured s ID Number: Enter the insured s ID number as shown on their Presbyterian ID card. 2 Required Patient s Name: Enter Last Name, First Name, and Middle initial (if applicable). 3 Required Patient s Birth Date and Sex: Enter the patient s date of birth in MMDDYYYY. Check the appropriate box indicating the patient s sex. 4 Required Insured s Name: Enter the insured s name as shown on their Presbyterian ID card. 5 Required Patient s Address: Enter the patient s mailing address and phone number in the appropriate fields. 6 Required Patient s Relationship to Insured: Enter an X in the appropriate box to indicate the patient s relationship to the insured. 7 Situational Insured s Address: Enter the insured s mailing address and phone number in the appropriate fields (not applicable if address is same as what you entered in Field 5). 8 Optional Patient s Status: Enter an X in the appropriate boxes to indicate the patient s status. 9 a-d Situational Other Insured s Name: If Item Number 11d is checked, complete these fields, otherwise leave blank. 10 a-c Required Is Patient s Condition Related to: Check boxes as appropriate. 10 d Not Used Reserved for Local Use: Leave this box blank. 11 a-c Required Insured s Policy Group or FECA Number: Enter the following insured s information in the appropriate fields: Group Number, Date of Birth, Sex, Employer s Name, Insurance Plan s Name 11 d Situational Is there Another Health Benefit Plan?: Enter an X in the appropriate box. If you checked Yes, Complete Fields 9, 9a-d. 12 Required Patient s or Authorized Person s Signature: Enter Signature on File, SOF, or legal signature. When entering a legal signature, enter the date signed. 13 Required Insured s or Authorized Person s Signature: Enter Signature on File, SOF, or legal signature. When entering a legal signature, enter the date signed. Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 3 of 10
Item Number Required Field? Description and Instructions 14 Situational Date of Current Illness, Injury, Pregnacy: Enter the date MMDDYYYY of the first date of the present illness, injury or pregnancy. 15 Situational If Patient Has Had Same or Similar Illness: Enter the first date (MMDDYYYY) the patient had the same or similar illness (previous pregnancies are not a similar illness). 16 Situational Dates Patient Unable to Work in Current occupation: Enter the dates (MMDDYYYY) that the patient is employed but unable to work. 17 Situational Name of Referring Provider or Other Source: Enter the name (First, Middle, Last) and credentials of professional who referred the patient. 17 a Optional Referring Physician or Other ID Number: Enter ZZ in the qualifier field and the Taxonomy code in field to the right of the qualifier. 17 b Situational Referring Physician NPI: Enter the NPI number of the referring physician. If Field 17 is completed, then 17 b is required. 18 Situational Hospitalization Dates Related to Current Services: Enter the dates (MMDDYYYY) when the patient was admitted and discharged from hospital. 19 Not Used Reserved for Local Use: Leave this field blank 20 Not Used Outside Lab?: Leave this field blank 21 Required Diagnosis or Nature of Illness or Injury: Enter the patient s diagnosis/condition. List up to 4 ICD-9-CM (diagnosis) Codes. (note: Diagnosis should be to the highest specificity) 22 Not Used Medicaid Resubmission: Leave this field blank 23 Situational Prior Authorization Number: Enter the benefit certification number as assigned by the payer for the current service. Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 4 of 10
Item Number Required Field? Description and Instructions 24 A Required Date(s) of Service: A from date of service must be entered. Enter to date of service if different than the from date. 24 B Required Place of Service: Enter a valid 2-digit place of service code. 24 C Not Used Emergency Indicator: Leave this field blank. 24 D Required Procedures, Services, or Supplies: Enter a 5-digit CPT or HCPCS code that identifies the service(s) performed. Enter up to 4 (four) valid 2-digit modifiers if appropriate for the services being performed. 24 E Required Diagnosis Pointer: Enter the diagnosis code reference number (pointer) as shown in field 21 to relate the date of service and procedures to the approppriate diagnosis. 24 F Required $ Charges: Enter the billed amount for the service line. Enter the dollar amounts to the left of the dotted line and the cents to the right of the dotted line. 24 G Required Days or Units: Enter the number of days or units using a numeric value. 24 H Situational EPSDT Family Plan: Enter a Y (for Yes) or N (for No) in the shaded area if the services are EPSDT related. Enter a Y or N in the non-shaded area to indicate if the services are family planning related. 24 I Required ID Qualifier: Enter ZZ in the qualifier field 24 J (upper) Situational Rendering Provider ID Number: Enter the Taxonomy code in upper field in 24 (to the right of the qualifier). This field is not required when billing is for a individual physician/practitioner who is not related to a group practice. 24 J (lower) Situational Rendering Provider ID Number: Enter the NPI number of the rendering physician in the lower field in 24. This field is not required when billing is for a individual physician/practitioner who is not related to a group practice. Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 5 of 10
Item Number Required Field? Description and Instructions 25 Required Federal Tax ID Number: Enter the billing provider s tax ID number. Check indicator box to identify what type of ID number it is. 26 Situational Patient s Account Number: Enter the patient s account number. 27 Required Accept Assignment? : Enter an X in the appropriate box if you accept assignment. 28 Required Total Charge: Enter the total of all service line charges. The total charge amount MUST equal the sum of all service line charges. 29 Situational Amount Paid: Enter the amount the patient or other payers paid on all service line charges. 30 Required Balance Due: Enter the total balance amount due on all service line charges. 31 Required Signature of Physician or Supplier: Enter the legal signature of the practitioner or supplier, representative, Signature on File. Enter the date (MMDDYYYY) the form was signed. 32 Situational Service Facility Location Information: Enter the service facility name and address. This field is required for all service locations other than 11 (Office). 32 a Situational Service Facility s NPI: Enter the service facility s NPI. This field is required for all service locations other than 11 (Office). 32 b Situational Service Facility s ID Qualifier: Enter ZZ in the qualifier field and the Taxonomy code of the service facility in the field to the right of the qualifier. 33 Required Billing Provider Info and Phone #: Enter the billing (pay to) provider s name, address and phone number in this field. (This field could be used to enter the provider s group name or the servicing provider s name.) 33 a Required Billing Provider s NPI: Enter the NPI number of the billing provider. 33 b Required Billing Provider s ID Qualifier: Enter ZZ in the qualifier field and the Taxonomy code of the billing provider in the field to the right of the qualifier. Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 6 of 10
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HELPFUL RESOURCES 1. Presbyterian Health Plan / Presbyterian Insurance Company Provider Page: http://www.phs.org/healthplan/providers/index.shtml 2. ACS Publication for NM Medicaid Fee-for-Service Program CMS-1500 (08-05) Billing Instructions: https://nmmedicaid.acs- inc.com/nm/pages/static/pdfs/medicaid%20publications/claimforminstr/cms- 1500%20instructions.pdf 3. National Uniform Claim Committee Reference Instruction Manual for the 08-05 Version: http://www.nucc.org/images/stories/pdf/claim_form_manual_v2-1_3-07.pdf 4. Center for Medicare & Medicaid Services (CMS) site for the National Provider Identifier Standard (NPI): http://www.cms.hhs.gov/nationalprovidentstand Presbyterian Health Plan / Presbyterian Insurance Company, Inc Original: 06/24/07 Page 10 of 10