NHIC Medicare CMS 1500 Instructions

CMS-1500

Claim Form Instructions

February 2008

NHIC, Corp.

MEDICARE

CMS-1500 Claim Form Instructions

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TABLE OF CONTENTS

Introduction.....................................................................................................................................3
Preparing the CMS-1500 claim form...............................................................................................4
The Form CMS-1500-(08-05) .........................................................................................................6
Instructions for Filling Out the Health Insurance Claim Form-1500 ..............................................10
Appendix A – Sample Wording For Authorizations.......................................................................30
Appendix B - Place of Service Codes with Definitions..................................................................31
Telephone and Address Directory ................................................................................................37
Mailing Address Directory.............................................................................................................38
Internet Resources .......................................................................................................................42 NHIC, Corp. 2 February 2008

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CMS-1500 Claim Form Instructions

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INTRODUCTION

The Provider Education and Outreach Team at NHIC, Corp. developed this guide to provide you with Medicare Part B CMS-1500 Claim Form Instructions. It is intended to serve as a useful supplement to other manuals published by NHIC, and not a replacement. The information provided in no way represents a guarantee of payment. Benefits for all claims will be based on the patient's eligibility, provisions of the Law, and regulations and instructions from Centers for Medicare & Medicaid Services (CMS). It is the responsibility of each provider or practitioner submitting claims to become familiar with Medicare coverage and requirements. All information is subject to change as federal regulations and Medicare Part B policy guidelines, mandated by the Centers for Medicare & Medicaid Services (CMS), are revised or implemented.

This information guide, in conjunction with the NHIC website (www.medicarenhic.com), Medicare B Resource (quarterly provider newsletter), and special program mailings, provide qualified reference resources. We advise you to check our website for updates to this guide. To receive program updates, you may join our mailing list by clicking on “Join Our Mailing List” on our website. Most of the information in this guide is based on Publication 100-04, Chapter 26 of the CMS Internet Only Manual (IOM). The CMS IOM provides detailed regulations and coverage guidelines of the Medicare program. To access the manual, visit the CMS website at http://www.cms.hhs.gov/manuals/

DISCLAIMER: This information release is the property of NHIC, Corp. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at www.medicarenhic.com and the CMS web site at www.cms.hhs.gov. The identification of an organization or product in this information does not imply any form of endorsement.

If you have questions or comments regarding this material, please call the appropriate NHIC Customer Service Center for your state. The telephone numbers are listed at the end of this guide. The CPT codes, descriptors, and other data only are copyright 2007 by the American Medical Association. All rights reserved. Applicable FARS/DFARS apply. The ICD-9-CM codes and their descriptors used in this publication are copyright 2007 under the Uniform Copyright Convention. All rights reserved. Current Dental Terminology, fourth edition (CDT-4) (including procedure codes, definitions (descriptions) and other data) is copyrighted by the American Dental Association. © 2006 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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PREPARING THE CMS-1500 CLAIM FORM

The Form CMS-1500 (Health Insurance Claim Form) is the standard claim form used by a non-institutional provider or supplier to bill Medicare contractors and durable medical equipment contractors when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The National Uniform Claim Committee (NUCC) is responsible for the maintenance of the form CMS-1500. CMS and contractors do not provide the form to providers for claim submission. Forms may be purchased from the U.S. Government Printing Office at (866) 512-1800, local printing companies in your area and/or office supply stores. Each of these sources sells the Health Insurance Claim Form CMS-1500 in various configurations (single part, multi-part, continuous feed, laser, etc.)

NUCC revised the Form CMS-1500. The new version, Form CMS-1500 (08-05) replaced the CMS-1500 (12-90) version. The 08-05 version of the CMS-1500 form was effective June 29, 2007. Medicare will reject any 12-90 version forms received.

For more information, please visit the CMS website at:

http://www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp

Intelligent Character Recognition (ICR)

NHIC is using an Intelligent Character Recognition (ICR) system to capture claims information directly from the CMS-1500 claim form.

ICR benefits include:

Greater efficiency;
Improved accuracy;
More control over the data input, and
Reduced data entry cost for the Medicare program.

The ICR is capable of going beyond simply scanning claims data into the computer and has a sophisticated computer “brain” which verifies claims information against several data files as well as performing various claims processing functions.

With the ICR system, it is important that claims be submitted with proper and legible coding. This is because the ICR output is largely dependent on the accuracy and legibility of the claim form submitted.
If you are not billing electronically, consider it! However, when you bill on paper, follow these tips when completing your CMS-1500 forms:

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The font should be:

Legible (Change typewriter ribbon/PC printer cartridge frequently, if necessary. Laser printers are

recommended)
In Black Ink
Pica, Arial 10, 11 or 12 font type
CAPITAL letters

The font must NOT have:

Broken characters
Script, Italics or Stylized font
Red ink
Mini-font
Dot Matrix font

Do NOT bill with:

Liquid correction fluid changes.
Data touching box edges or running outside of numbered boxes (left justify information in each box).

Exception: when using the 8-digit date format, information may be typed over the dotted lines shown in date fields, i.e., Item 24a.
More than six service lines per claim (use a new form for additional services);
Narrative descriptions of procedure, narrative description of modifier or narrative description of

diagnosis (the CPT, Modifier or ICD-9-CM codes are sufficient);
Stickers or rubber stamps (such as “tracer,” “corrected billing,” provider name and address, etc.);
NHIC's address at top of the form;
Special characters (i.e., hyphens, periods, parentheses, dollar signs and ditto marks).
Handwritten descriptions;
Attachments smaller than 8 1/2 x 11.

The claim form must be:

An original CMS-1500 printed in red “drop out “ ink with the printed information on back (photocopies

are not acceptable);
Size - 8½ ” x 11” with the printer pin-feed edges removed at the perforations;
Free from crumples, tears, or excessive creases (to avoid this, submit claims in an envelope that is full

letter size or larger);
Thick enough (20-22 lbs.) to keep information on the back from showing through;
Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out

information or white out.

NOTE: The following examples are in black and white. An original CMS-1500 claim form is printed in red “drop out” ink with the printed information on the back.

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THE FORM CMS-1500-(08-05)

The Form CMS-1500 answers the need of many health insurers. It is the basic form prescribed by CMS for the Medicare program and is only accepted from physicians and suppliers that are excluded from the mandatory electronic submission requirement. The instructions for completion of the paper claim form provide required and conditional elements that are also applicable to electronic billing. Consult your Medicare-specific Companion Document to the Implementation Guide for Health Care Claim Professional 837 for assistance with electronic billing.

Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all other fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31).

Providers of service and suppliers have the option of entering 6 or 8-digit dates in items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit dates for all these fields. For instance, a provider or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19, and a 6-digit date for item 24a. The same applies to providers and suppliers who choose to submit 6-digit dates. Items 12 and 31 are exempt from this requirement.

Mandatory Reporting of the NPI on all Part B Claims

Effective March, 1, 2008, your Medicare fee-for-service claims must include an NPI in the primary provider fields on the claim (i.e.; the billing, pay-to-provider, and rendering provider fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI. The secondary provider fields (i.e.; referring, ordering, and supervising) may continue to include only your legacy number, if you choose. Failure to submit an NPI in the primary provider identifier fields will result in your claims being rejected.

As of May 23, 2008, all claims must be submitted with NPI only in all primary and secondary fields. Claims containing legacy numbers will be rejected.

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INSTRUCTIONS FOR FILLING OUT THE HEALTH INSURANCE CLAIM

FORM-1500

CONTRACTOR NOTE: Items marked with “R” (Required) or “C” (Conditionally Required) will cause your claim to be rejected if they are missing, invalid, or incomplete. However, there are many other items on the claim form which must be properly completed, or your claim will be developed, delayed or denied.
Publications (Pub.) referenced in the instructions refer to the CMS Internet Only Manual (IOM).

Reminder: For date fields other than date of birth, all fields shall be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

Item 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.

CONTRACTOR NOTE: Do not use dashes in number. Be sure to add the letter suffix.

Item 1a:
®

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

ANYWHERE CA

56789 111 555-1212

Illustration for Items 2 though 6.

Item 2: ®	Enter the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card. This is a required field.
Item 3:	Enter the patient's 8-digit birth date (MM/DD/CCYY) and sex.
Item 4: ©	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 Medicare is primary, leave blank.

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Item 5:		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 phone number.
Item 6: ©		Check the appropriate box for patient's relationship to insured when item 4 is completed.
Item 7: ©		Enter the insured's address and telephone number. When the address is the same as the patient's, use the word SAME. Complete this item only when items 4, 6 and 11 are completed.
Item 8:		Check the appropriate box for the patient's marital status and whether employed or a student.

Item 9:		Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans. NOTE: Only participating physicians and suppliers are to complete Item 9 and its subdivisions and only when the Beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier. Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the patient. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a patient elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. 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 (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to 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 applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as

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		“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 item 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 contractor to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.
		03 25 1919 X 123456789
		Illustration for Items 9 though 9d.
Item 9a: ©		Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.

NOTE: Item 9d must be completed, even when the provider enters a policy and/or group number in Item 9a.

Item 9b: ©		Enter the Medigap insured's 8-digit birth date (MM/DD/CCYY) and sex.
Item 9c: ©		Leave blank if a Medigap PAYERID is entered item 9d. Otherwise, enter the claims processing address of 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.”

Item 9d:
©

Enter in the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists,
then enter the Medigap insurance program or plan name.

If the Medicare beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or

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supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d. A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary's claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor will be unable to forward the claim information to the Coordinator of Benefits Contractor.

CONTRACTOR NOTE : The Medigap claim-based IDs that fall in the range of 55000 through 59999 can be found on the CMS website at

http://www.cms.hhs.gov/COBAgreement/Downloads/Medigap%20Claim-based%20COBA%20IDs%20for%20Billing%20Purpose.pdf

Item 10a-c:	Check “YES” or “NO” to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked “YES” indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.
Item 10d:	Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, this item must show the patient's Medicaid number preceded by MCD.
Item 11: ®	THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.

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Illustration for item 11 through 11d.

If there is insurance primary to Medicare, enter the insured's policy or group number and
proceed to items 11a-11c. Items 4, 6, and 7 must also be completed.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is
indicated in item 11.

If there is no insurance primary to Medicare, enter the word “NONE” and then proceed to
item 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 item 11b.

If a lab has previously collected and retained MSP information for a beneficiary, the lab may
use that information for billing purposes of the non-face-to-face lab service. If the lab has no
MSP information for the beneficiary, the lab will enter the word “None” in item 11 of Form
CMS-1500, when submitting a claim for payment of a reference lab service, where there has
been no face-to-face encounter with the beneficiary. The claim will then follow the normal

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claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected
to collect the MSP information and bill accordingly.

Insurance Primary to Medicare— Circumstances under which Medicare payment may be
secondary to other insurance include:

Group Health Plan Coverage:

— Working Aged;

— Disability (Large Group Health Plan); and

— End Stage Renal Disease.
No-Fault and/or Other Liability; and
Work Related Illness/Injury:

— Workers' Compensation;

— Black Lung; and

— Veterans Benefits.

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. (See Pub. 100-05, Medicare Secondary Payer Manual, Chapter 3).

CONTRACTOR NOTE: See the Medicare Secondary Payer Billing Guide in the Publications section of our website: http://www.medicarenhic.com

Item 11a: ©		Enter the insured's 8-digit birth date (MM/DD/CCYY) and sex if different from item 3.
Item 11b: ©		Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., enter either a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) retirement date preceded by the word “RETIRED.”
Item 11c: ©		Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID numbers exist, then enter the complete primary payer's program or plan name. 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. This is required if there is insurance primary to Medicare that is indicated in item 11.
Item 11d:		Leave blank. Not required by Medicare.
Item 12: ®		The patient or authorized representative must sign and enter either a 6-digit date (MM/DD/YY), 8-digit date (MM/DD/CCYY), or an alpha numeric date (e.g., January 1, 2004) 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 in accordance with Chapter 1, “General Billing Requirements” (Pub. 100-4, Section 26). If the patient is physically or mentally unable to sign, a representative specified in Chapter 1, “General Billing Requirements” (Pub. 100-4, Section 26) may sign on the patient's behalf. In this

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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 can
not sign. The authorization is effective indefinitely unless the patient or the patient's
representative revokes this arrangement.

Note: This can be “Signature on File” and/or a computer generated signature.

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

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

Item 13:

The patient's signature or the statement “signature on file” in this item authorizes payment
of medical benefits to the physician or supplier. The patient or his/her authorized
representative signs this item or the signature must be on file separately with the provider
as an authorization. However, note that when payment under the Act can only be made on
an assignment-related basis or when payment is for service furnished by a participating
physician or supplier, a patient's signature or a “signature on file” is not required in order
for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurer) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

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

NOTE: This can be “Signature on File” signature and/or a computer generated signature.

CONTRACTOR NOTE: The presence of a signature, or the statement “signature on file and/or SOF is recognized.

Item 14:
©

Enter either a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date of current illness,
injury, or pregnancy. For chiropractic services, enter a 6-digit (MM/DD/YY) or 8-digit
(MM/DD/CCYY) date of the initiation of the course of treatment and enter a 6-digit
(MM/DD/YY) or 8-digit (MM/DD/CCYY) date in item 19.

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Item 15:		Leave blank. Not required by Medicare.
Item 16:		If the patient is employed and is unable to work in current occupation, enter a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.
Item 17: ©		Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring service.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;

3. A doctor of podiatric medicine for purposes of §§(k), (m), (p) (1), and (s) and §§1814(a), 1832(a) (2) (F) (ii), and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;

4. A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or

5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §§1861(s) (1) and 1861(s) (2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a) (4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a) (4) of the Act) are furnished.

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

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Ordering physician is a physician or, when appropriate, a non-physician practitioner, who
orders non-physician services for the patient. See Pub. 100-02, Chapter 15 for non-physician
practitioner rules. Examples of services that might be ordered include diagnostic laboratory
tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and
services incident to that physician's or non-physician practitioner's service.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of physician's order or referral shall include the ordering/referring physician's name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider's UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:

fl Medicare covered services and items that are the result of a physician's order

or referral;

fl Parenteral and enteral nutrition;

fl Immunosuppressive drug claims;

fl Hepatitis B claims;

fl Diagnostic laboratory services;

fl Diagnostic radiology services;

fl Portable x-ray services;

fl Consultative services;

fl Durable medical equipment

fl When the ordering physician is also the performing physician (as often is the case

with in-office clinical laboratory tests);

fl When a service is incident to the service of a physician or non-physician practitioner,

the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;

fl When a physician extender or other limited licensed practitioner refers a patient for

consultative service, submit the name of the physician who is supervising the limited licensed practitioner;

Illustration for Item 17 though 17b.

Item 17a: Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

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Item 17b:

Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order
services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a
service was ordered or referred by a physician.

CONTRACTOR NOTE: Surrogate UPINs: If the ordering/referring physician has not been
assigned a UPIN , one of the surrogate UPINs listed below may be used in item 17a through
May 22, 2008. As of May 23, 2008, only NPIs will be accepted.

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 item 17 and the surrogate UPIN in item
17a. Claims received with surrogate numbers will be tracked and possibly audited.

PHS000-Physicians serving in the Public Health Serves, including the Indian Health Service
RES000-Physicians meeting the description of intern, resident or fellow
RET000-Retired Physicians who were not issued a UPIN
VAD000-Physicians serving in the Department of Veterans Affairs or U.S. Armed Forces
OTH000-Does not meet criteria for other surrogates and has not been assigned a UPIN

Effective for services rendered January 3, 2006, and later Medicare will no longer accept the
surrogate UPINs on IDTF claims.

Item 18:

Enter either an 8-digit (MM/DD/CCYY) or a 6-digit (MM/DD/CCYY) date when a
medical service is furnished as a result of, or subsequent to, a related hospitalization.

Item 19:

Enter either a 6-digit (MM/DD/YY) or an 8-digit (MM/DD/CCYY) date patient was last

seen and the UPIN (NPI when it becomes required) of his/her attending physician when a
physician providing routine foot care submits claims.

For physical therapy, occupational therapy or speech-language pathology services, effective
for claims with dates of service on or after June 6, 2005, the date last seen and the UPIN/NPI
of an ordering/referring/attending/certifying physician or non-physician practitioner are
not required. If this information is submitted voluntarily, it must be correct or it will cause
rejection or denial of the claim. However, when the therapy service is provided incident to
the services of a physician or nonphysician practitioner, the incident to policies continue to
apply. For example, for identification of the ordering physician who provided the initial
service, see Item 17 and 17a, and for the identification of the supervisor, see item 24J of this
section.

NOTE: Effective May 23, 2008, all identifiers on the Form CMS-1500 MUST be in the form of
an NPI.

Enter either a 6-digit (MM/DD/YY) or an 8-digit (MM/DD/CCYY) x-ray date for

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chiropractor services (if an x-ray, rather than a physical examination was the method used
to demonstrate the subluxation). By entering an x-ray date and the initiation date for course
of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of subluxation) of the Pub. 100-02 Medicare Benefits Policy Manual, Chapter 15, are on file, along with the appropriate x-ray and all are available for carrier review.

Enter the drug's name and dosage when submitting a claim for Not Otherwise Classified
(NOC) drugs.

CONTRACTOR NOTE: Include route of administration if various routes are available for
administration.

Enter a concise description of an “unlisted procedure code” or an NOC code if one can be
given within the confines of this box. Otherwise, an attachment shall be submitted with the
claim.

Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d.
If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers
for each line item containing a -99 modifier 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.

CONTRACTOR NOTE: Contractors can now accept up to four modifiers on a line. If more than four are needed, use the instructions listed above.

Enter the statement "Homebound" when an independent laboratory renders an EKG
tracing or obtains a specimen from a homebound or institutionalized patient. (See Pub.
100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other
Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16,
"Laboratory Services From Independent Labs, Physicians and Providers," and Pub. 100-
01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5,
"Definitions," respectively for the definition of "homebound" and a more complete
definition of a medically necessary laboratory service to a homebound or an institutional
patient.)

Enter the statement, “Patient refuses to assign benefits” when the beneficiary absolutely refuses to assign benefits to a non participating physician/supplier who accepts assignment on the claim. In this case, payment can only be made directly to the beneficiary.

Enter the statement, “Testing for hearing aid” when billing services involving the testing of
a hearing aid(s) to obtain intentional denial when other payers are involved.

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

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

Enter a 6-digit (MM/DD/YY) or an 8-digit (MM/DD/CCYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care.

Enter demonstration ID number "30" for all national emphysema treatment trial claims.

Enter theNPI/PIN of the physician who is performing a purchased interpretation of a diagnostic test. (See Pub. 100-04, Chapter 1, Section 30.2.9.1 for additional information.)

NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be
in the form of an NPI.

Method II suppliers shall enter the most current HCT value for the injection of Aranesp
for ESRD beneficiaries on dialysis. (See Pub. 100-04, Chapter 8, Section 60.7.2.)

Effective January 1, 2008, individuals and entities who bill for administration of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit or hemoglobin test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point[xx.x]). Examples for hemoglobin test: TR/RI9.0. Example of Hematocrit tests: TR/R2/27.0

For more information including modifiers that may apply, please see MLN Matter Article on the CMS website at

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5699.pdf

Effective April 1, 2008, the 8-digit Clinical Trial Number may be voluntarily entered. Preface the numeric 8-digit clinical trial registry number with CT. For example, CT12345678.

CONTRACTOR NOTE: Additional conditions have been added for specific covered items. For Ambulance claims, please refer to the Ambulance Billing Guide.

Item 20:
©

Complete this item when billing for diagnostic tests subject to purchase price limitations.
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, item 32 shall be completed. When billing for multiple purchased diagnostic tests,
each test must be submitted on a separate claim Form CMS-1500. Multiple purchased
diagnostic tests may be submitted on the ASC X12 837 electronic format as long as

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appropriate line level information is submitted when services are rendered at different facility service locations.

NOTE: This is a required field when billing for diagnostic tests subject to purchase price
limitations.

CONTRACTOR NOTE: Only services with technical components paid under the Medicare
Physician Fee Schedule are subject to purchased diagnostic rules. Clinical laboratories are not
subject to the purchased diagnostic rules.

Item 21:
©

Enter the patient's diagnosis/condition. With the exception of claims submitted by
ambulance suppliers (specialty type 59), all physician and non-physician specialties (i.e., PA,
NP, CNS, CRNA) use an ICD-9-CM code number and code to the highest level of specificity
for the date of service. Enter up to four diagnoses in priority order. All narrative diagnoses
for nonphysician specialties shall be submitted on an attachment.

466 19 464 00

465 0 034 0

Item 22:

Leave blank. Not required by Medicare.

Item 23:
©

Enter the Quality Improvement Organization (QIO) prior authorization number for those
procedures requiring QIO prior approval.

Enter the Investigational Device Exemption (IDE) number when an investigational device is
used in an FDA-approved clinical trial. Post Market Approval (PMA) number should also
be placed here when applicable.

CONTRACTOR NOTE: The IDE/ PMA number has one alpha character and six numeric
digits.

For physicians performing care plan oversight services, enter the 6-digit Medicare
provider number (or NPI when effective) of the home health agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed.

CONTRACTOR NOTE: Effective October 2, 1006, the requirement to include the Home Health Agency (HHA) or hospice provider number on a CPO claim is temporarily
waived by CMS. There is currently no place on the HIPAA standard ASC X 12N 837

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format to specifically include the HHA or hospice number. Submitted claims that
include the HHA or hospice provider number will re returned to the provider as
unprocessable, until further notice

Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for
laboratory services billed by an entity performing CLIA covered procedures.

CONTRACTOR NOTE: For ambulance claims, enter the zip code for the point of pick up in this field. More than one ambulance service may be reported on the same claim for a beneficiary if all points of pickup have the same ZIP code. Suppliers must prepare a separate claim for each trip if the points of pickup are located in different ZIP codes. Claims without a ZIP code in item 23, or with multiple ZIP codes in item 23, will be returned as unprocessable.

llustration for item 23.

NOTE : Item 23 can contain only 1 condition. Any additional conditions must be reported on
a separate Form CMS-1500.

Item 24:

The six service lines in section 24 have been divided horizontally to accommodate
submission of both the NPI and legacy identifier during the NPI transition
and to accommodate the submission of supplemental information to support the billed
service. The top portion in each of the six service lines is shaded and is the location for
reporting supplemental information. It is not intended to allow the billing of 12 service lines.

When required to submit NDC drug and quantity information for Medicaid rebates,
submit the NDC code in the red shaded portion of the detail line item in positions 01
through position 13. The NDC is to be preceded with the qualifier N4 and followed
immediately by the 11 digit NDC code (e.g., N499999999999). Report the NDC quantity
in positions 17 through 24 of the same red shaded portion. The quantity is to be
preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or
ML (milliliter). There are six bytes available for quantity. If the quantity is less than six
bytes, left justify and space fill the remaining positions (e.g. UN2 or F2999999).

CONTRACTOR NOTE: NDC Coding may be submitted after April 7, 2008. For more
information, see MLN Matters Article on the CMS website at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5835.pdf

Item 24A:
®

Enter a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date 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. The contractor will return as unprocessable
if date of service extends more than 1 day and a valid "to" date is not present.

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Item 24B: ®	Enter the appropriate place of service code(s) from the list provided in Section 10.5. Identify the location, using a place of service code, for each item used or service performed. NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code. CONTACTOR NOTE: The Place of Service codes can be found in Appendix B of this Guide.
Item 24C:	Medicare providers are not required to complete this item.
Item 24D: ®	Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The Form CMS-1500 (08-05) has the ability to capture up to four modifiers.
	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 item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment shall be submitted with the claim. The contractor will return as unprocessable if an “unlisted procedure code” or an (NOC) code is indicted in item 24d, but an accompanying narrative is not present in item 19 or on an attachment. CONTRACTOR NOTE: The Centers for Medicare & Medicaid Services Healthcare Common Procedure Code System (HCPCS) is the coding system used by Medicare B nationwide and consists of two levels of codes and modifiers used by Medicare. Level I contain the American Medical Association's (AMA) CPT codes and modifiers which are numeric. Level II contains alpha-numeric codes and modifiers primarily for items and non-physician services not included in CPT (e.g., ambulance, drugs/biologicals, DME, orthotics, prosthetics).
Item 24E: ®	Enter the diagnosis code reference number as shown in item 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.

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If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), the provider shall reference only one of the diagnoses in item 21.

04 01 2007 04 01 2007 11 99212 1

04 02 2007 04 02 2007 11 99212 2

Illustration for Item 24E.

Item 24F:
®

Enter the charge for each listed service.

Illustration for Item 24F through 24J

Item 24G:
®

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.

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

For instruction on submitting units for oxygen claims, see Pub.100-04, Chapter 20, Section
130.6

NOTE: This field should contain at least 1 day of unit. The carrier should program their system to automatically default to “1” unit when information in this field is missing to avoid returning as unprocessable.

Item 24H:		Leave blank. Not required by Medicare.
Item 24I:		Enter the ID qualifier 1C in the shaded portion.
Item 24J:		Enter the rendering provider's PIN in the shaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion. Enter the rendering provider's NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion. NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.
Item 25:		Enter the provider of service or supplier Federal Tax I.D. (Employer Tax Identification number or Social Security Number) and check the appropriate check box. Medicare providers are not required to complete this item for crossover purposes since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim. However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claim submitted without tax identification information will/may be delayed.
Item 26:		Enter the patient's account number assigned by the provider's of service or supplier's ac- counting system. This field is optional to assist the provider in patient identification. As a service, any account numbers entered here will be returned to the provider.
Item 27:		Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and must accept assignment of Medicare benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on assignment
basis:

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Clinical diagnostic laboratory services;
Physician services to individuals dually entitled to Medicare and Medicaid;
Participating physician/supplier services;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse mid

wives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
Ambulatory surgical center services for covered ASC procedures;
Home dialysis supplies and equipment paid under Method II;
Ambulance services;
Drugs and biologicals and
Simplified billing roster for influenza virus vaccine and pneumococcal vaccine

Item 28:		Enter total charges for the services (i.e., total of all charges in item 24f).
Item 29:		Enter the total amount the patient paid on the covered services only.

CONTRACTOR NOTE: We recommend this be left blank, as it is often misunderstood and can
cause incorrect payments.

Item 30:

Leave blank. Not required by Medicare.

Item 31:

Enter the signature of the provider of service or supplier, or his/her representative, and either
the 6-digit (MM/DD/YY) or 8-digit date (MM/DD/CCYY) date, or alphanumeric date (e.g.,
January 1, 2007) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non- physician practitioner providing the direct supervision in item 31.

NOTE: This is a required field; however, the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.

Item 32: Enter the name and address and ZIP code of the service location of all services other than those furnished in place of service home-12.

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MEDICARE, MEDICARE & MORE INC

1234 HEALTHCARE STREET

ANYTOWN, CA 91234

Illustration for Item 32 through 32b.

Effective for claims received on or after April 1, 2004, enter the name, address, and zip code of the service location for all services other than those furnished in place of service home –

Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and ZIP code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted.

Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in Chapter 1 of IOM Publication 100-04, for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.

For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.

If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home.

If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.

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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.

Item 32a : If required by Medicare claims processing policy, enter the National Provider Identifier (NPI)

of the service facility.

CONTRACTOR NOTE: At the present time, only claims for purchased diagnostic services require the entry of an NPI number .

Item 32b:

If required by Medicare claims processing policy, enter the PINof the service facility. Be sure
to precede the PIN with the ID Qualifier 1C. There should be one blank space between the
qualifier and the PIN.

NOTE: Effective May 23, 2008, Item 32b is not to be reported.

Item 33:
®

Enter the provider of service/supplier's billing name, address, ZIP code, and telephone
number.

111 555-1212

MEDICARE, MEDICARE & MORE INC.

1234 HEALTHCARE STREET

ANYTOWN, CA 91234

Illustration for Item 33 though 33b.

Item 33a :

Enter the NPI of the billing provider or group.

Item 33b:

Enter the ID qualifier 1C followed by one blank space and then the PIN of the billing
provider or group. When NPI is required, 33b is not to be reported. Suppliers billing the
DME MAC will use the National Supplier Clearinghouse (NSC) number in this item.

NOTE: Effective May 23, 2008, Item 33b is not to be reported.

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APPENDIX A – SAMPLE WORDING FOR AUTHORIZATIONS

ONE-TIME AUTHORIZATION

For Use by Provider

Beneficiary Name____________________________HIC#___________________________

I request that payment of authorized Medicare benefits be made to me or on my behalf to (Provider Name) for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.

___________________________________________Date_________________

(Beneficiary signature)

For Use by a Facility

Beneficiary Name_______________________________________HIC#________________

I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in (Name of Facility), including provider services. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or benefits for related services.

____________________________________________Date________________

(Beneficiary signature)

MEDIGAP AUTHORIZATION

Beneficiary Name________________________________________HIC#_______________
Medigap Policy Number_______________________________________

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

_____________________________________________Date_______________

(Beneficiary signature)

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APPENDIX B - PLACE OF SERVICE CODES WITH DEFINITIONS

Place of Service Code(s)	Place of Service Name	Place of Service Description
01	Pharmacy	A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
02	Unassigned	N/A
03	School	A facility whose primary purpose is education.
04	Homeless Shelter	A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).
05	Indian Health Service Free-standing Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non- surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.
06	Indian Health Service Provider-based Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non- surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.
07	Tribal 638 Free-standing Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization.
08	Tribal 638 Provider- based Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients
09	Prison-Correctional Facility	A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. (effective 7/1/06)
10	Unassigned	N/A

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11	Office	Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
12	Home	Location, other than a hospital or other facility, where the patient receives care in a private residence.
13	Assisted Living Facility	Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.
14	Group Home	A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).
15	Mobile Unit	A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
16	Temporary Lodging	Effective April 1, 2008 A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.
17-19	Unassigned	N/A
20	Urgent Care Facility	Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
21	Inpatient Hospital	A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22	Outpatient Hospital	A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23	Emergency Room – Hospital	A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

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24	Ambulatory Surgical Center	A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
25	Birthing Center	A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.
26	Military Treatment Facility	A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
27-30	Unassigned	N/A
31	Skilled Nursing Facility	A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32	Nursing Facility	A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
33	Custodial Care Facility	A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34	Hospice	A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.
35-40	Unassigned	N/A
41	Ambulance - Land	A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42	Ambulance – Air or Water	An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
43-48	Unassigned	N/A
49	Independent Clinic	A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (effective 10/1/03)

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50	Federally Qualified Health Center	A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51	Inpatient Psychiatric Facility	A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility- Partial Hospitalization	A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53	Community Mental Health Center	A facility that provides the following services: 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 health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54	Intermediate Care Facility/Mentally Retarded	A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
55	Residential Substance Abuse Treatment Facility	A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56	Psychiatric Residential Treatment Center	A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57	Non-residential Substance Abuse Treatment Facility	A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. (effective 10/1/03)

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58-59	Unassigned	N/A
60	Mass Immunization Center	A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.
61	Comprehensive Inpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62	Comprehensive Outpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
63-64	Unassigned	N/A
65	End-Stage Renal Disease Treatment Facility	A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
66-70	Unassigned	N/A
71	Public Health Clinic	A facility maintained by either State or local health departments that provide ambulatory primary medical care under the general direction of a physician. (effective 10/1/03)
72	Rural Health Clinic	A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
73-80	Unassigned	N/A
81	Independent Laboratory	A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.
82-98	Unassigned	N/A
99	Other Place of Service	Other place of service not identified above.

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TELEPHONE AND ADDRESS DIRECTORY

Provider Interactive Voice Response (IVR) Directory

All actively enrolled providers must utilize the IVR for: Beneficiary Eligibility, Deductible, Claim Status, Check Status and Earnings to Date. The IVR can also assist you with the following

information: Seminars, Telephone Numbers, Addresses, Medicare News and Appeal Rights.

Available 24 hours/day, 7 days/week (including holidays)

1-877-591-1587
1-866-502-9054

California

Northern
Southern

Available 24 hours/day, 7 days/week (including holidays)

1-877-591-1587
1-866-502-9054

Provider Customer Service Directory

Our Customer Service representatives will assist you with questions that cannot be answered by the IVR, such as policy questions, specific claim denial questions, 855 application status, redetermination status (formerly Appeals). Per CMS requirements, the Customer Service representatives may not assist providers with Beneficiary Eligibility, Deductible, Claim Status, Check Status and Earnings to Date unless we are experiencing IVR system problems. This rule applies even if the caller has obtained the code.

Hours of Operation: 8:00 a.m. to 4:00 p.m. Monday – Friday

California

1-877-527-6613

New England

Maine
Massachusetts
New Hampshire
Vermont

1-877-258-4442
1-877-527-6594
1-877-258-4442
1-877-258-4442

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MAILING ADDRESS DIRECTORY

Northern California Medicare Provider Certification		P.O. Box 2812 Chico, CA 95927-2812
Medicare Preferred Provider		P.O. Box 2804 Chico, CA 95927-2804
Medicare Secondary Payer		P.O. Box 2004 Chico, CA 95927-2004
MSP Cash		O. Box 951 Marysville, CA 95901-951
Medicare Written Inquiries/MSP		P.O. Box 2006 Chico, CA 95927-2006
Medicare Redetermination		P.O. Box 2800 Chico, CA 95927-2800
Medicare Payment Safeguard		P.O. Box 2806 Chico, CA 95927-2806
Medicare EDI		P.O. Box 2807 Chico, CA 95927-2807

Medicare ADS (Automated Development System) P.O. Box 2009

Chico, CA 95927-2009

Medicare Redetermination O/P (Overpayments)	P.O. Box 2808 Chico, CA 95927-2808
Cash Accounting	P.O. Box 391 Marysville, CA 95901-391
Medicare Reconsideration	P.O. Box 2811 Chico, CA 95927-2811

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Southern California Medicare Claims				P.O. Box 272852 Chico, CA 95927-2852
Medicare Secondary Payer				P.O. Box 272855 Chico, CA 95927-2855
Overpayment Recoup Checks				P.O. Box 515301 Los Angeles, CA 90051-6601
Medicare Overpayments (Undeliverable Checks)				P.O. Box 515302 Los Angeles, CA 90051-6602
Medicare Written Inquiry				P.O. Box 272857 Chico, CA 95927-2857
Medicare Redetermination				P.O. Box 272854 Chico, CA 95927-2854
Medicare Administrative Mail ATTN: (Insert name of person)				P.O. Box 54905 Los Angeles, CA 90054-0905
California - Benefit Integrity Support (BISC)				P.O. Box 51447 Los Angeles, CA 90051-5747
Medicare Electronic Data Interchange (EDI)				P.O. Box 2807 Chico, CA 95927-2807
Medicare ADS (Development Letters)				P.O. Box 272859 Chico, CA 95927-2859
Undeliverable Mail				P.O. Box 54113 Los Angeles, CA 90054-0113
Third Party Liability (TPL)/ Worker's Comp.				P.O. Box 515391 Los Angeles, CA 90051-6691
Medicare Redetermination Overpayment				P.O. Box 2808 Chico, CA 95927-2808
Medicare Reconsideration				P.O. Box 515300 Los Angeles, CA 90051-6601

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New England

Initial Claim Submission Maine		P.O. Box 2323 Hingham, MA 02044
Massachusetts		P.O. Box 1212 Hingham, MA 02044
New Hampshire		P.O. Box 1717 Hingham, MA 02044
Vermont		P. O. Box 7777 Hingham, MA 02044
EDI (Electronic Data Interchange)		P.O. Box 9104 Hingham, MA 02044
Written Correspondence/Overpayments/ Redetermination		P.O. Box 1000 Hingham, MA 02044
Medicare B Refunds		Medicare B Accounting Control P.O. Box 9103 Hingham, MA 02044
Medicare Secondary Payer (Correspondence Only)		P.O. Box 9100 Hingham, MA 02044
Provider Enrollment		P.O. Box 3434 Hingham, MA 02044
Program Safeguard Contractor (PSC) Benefit Integrity Support Center NE-BISC		P.O. Box 4444 Hingham, MA 02044

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Durable Medical Equipment (DME)

For information, please contact the DME Regional Contractor for your area.

California Durable Medical Equipment (DME) Contractor:

Noridian Administrative Services General Medicare Information: 1-866-243-7272

Please view the website to find the appropriate address:

https://www.noridianmedicare.com/dme/contact/contact.html

New England Durable Medical Equipment (DME) Medicare Administrative Contractor:

NHIC, Corp. Provider Service Line: 1-866-419-9458

Please view the website to find the appropriate address:

http://www.medicarenhic.com/dme/contacts.shtml

Reconsideration (Second Level of Appeal)

New England and California

First Coast Service Options Inc.

QIC Part B North Reconsiderations

P.O. Box 45208

Jacksonville, FL 32232-5208

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INTERNET RESOURCES

The Internet is a very valuable tool in researching certain questions or issues. NHIC has a comprehensive website that serves as a direct source to Medicare as well as a referral tool to other related websites that may prove to be beneficial to you.

NHIC, Corp.

http://www.medicarenhic.com

Upon entering NHIC's web address you will be first taken straight to the “home page” where there is a menu of information. NHIC's web page is designed to be user-friendly.

We encourage all providers to join our website mailing list. Just click the link on the home page entitled “Join Our Mailing List”. You may also access the link directly at: http://visitor.constantcontact.com/email.jsp?m=1101180493704

When you select the “General Website Updates”, you will receive a news report every week, via e-mail, letting you know what the latest updates are for the Medicare program. Other Web News selections (CA Updates, NE Updates, EDI, etc.) will be sent out on an as-needed basis.

Provider Page Menus/Links

From the home page, click either the “California Providers” or “New England Providers” link. This will take you to the License for use of "Physicians' Current Procedural Terminology", (CPT) and "Current Dental Terminology", (CDT). Scroll down to bottom of the page. Once you click “Agree”, you will be taken to the provider pages.

On the left side of the web page you will see a menu of topics that are available. Explore each one and bookmark those that you use most often.

Medicare Coverage Database

http://www.cms.hhs.gov/center/coverage.asp

http://www.cms.hhs.gov/mcd/indexes.asp

The Medicare Coverage Database is an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. It features Local Coverage Determinations (LCDs) developed by Medicare Contractors and National Coverage Determinations (NCDs) developed by CMS. CMS requires that local policies be consistent with national guidance (although they can be more detailed or specific), developed with scientific evidence and clinical practice.

Medicare Learning Network

http://www.cms.hhs.gov/MLNGenInfo/

The Medicare Learning Network (MLN) website was established by CMS in response to the increased usage of the Internet as a learning resource by Medicare health care professionals. This website is designed

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to provide you with the appropriate information and tools to aid health care professionals about Medicare. For courses and information, visit the web site. For a list of the Training Programs, Medicare Learning Network Matters articles and other education tools available, visit the website.

Open Door Forums

http://www.cms.hhs.gov/OpenDoorForums/

CMS conducts Open Door Forums. The Open Door Forum addresses the concerns and issues of providers. Providers may participate by conference call and have the opportunity to express concerns and ask questions. For more information, including signing up for the Open Door Forum mailing list, visit the website.

Publications and Forms

http://www.cms.hhs.gov/CMSForms/

http://www.cms.hhs.gov/MedicareProviderSupEnroll/

For your convenience CMS has published optional forms, standard forms, and SSA forms. By linking onto the Publications site you can access the following forms:
For your convenience CMS has published optional forms, standard forms, and SSA forms. By linking onto this website, you can access numerous CMS forms such as:

Provider Enrollment CMS 855 forms (CMS 855B, 855I, & 855R)
Medicare Participating Physician or Supplier Agreement (CMS 460)
Advanced Beneficiary Notices (ABN) (CMS R-131- G, R-131-L, & 20007)
Medicare Redetermination Request Form (CMS 20027)
Request for Hearing (CMS 1965)
Medicare Managed Care Disenrollment form (CMS 566)

Advance Beneficiary Notice (ABN)	http://cms.hhs.gov/BNI/
American Medical Association	http://www.ama-assn.org/
CMS	http://www.cms.hhs.gov http://www.medicare.gov
CMS Correct Coding Initiative	http://www.cms.hhs.gov/NationalCorrectCodInitEd/
CMS Physician's Information Resource for Medicare	http://www.cms.hhs.gov/center/physician.asp?
Evaluation & Management Documentation Guidelines	http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

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Federal Register	http://www.archives.gov/federal-register http://www.gpoaccess.gov/index.html
HIPAA	http://www.cms.hhs.gov/HIPAAGenInfo/
National Provider Identifier (NPI)	http://www.cms.hhs.gov/NationalProvIdentStand/
NPI Registry	https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
U.S. Government Printing Office	http://www.gpoaccess.gov/index.html

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NHIC, Corp.

75 Sgt. William Terry Drive Hingham, MA 02044

1055 West 7th Street

Los Angeles, CA 90017

620 J Street

Marysville, CA 95901

Website:

http://www.medicarenhic.com

CMS Websites

http://www.cms.hhs.gov

http://www.medicare.gov

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