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CO HCPF Doula Billing Manual — CMS 1500 Paper Claim Reference Table
CMS1500PaperClaimReferenceTable
Thefollowingpaperformreferencetableshowsrequired,optional,andconditionalfieldsanddetailedfieldcompletioninstructionsfortheCMS1500claimform.
CMSFieldNumber&Label
Fieldis?
Instructions
1.InsuranceType
Required
Placean"X"intheboxmarkedasMedicaid.
1a.Insured'sIDNumber
Required
Enterthemember'sHealthFirstColoradoseven(7)-digitHealthFirstColoradoIDnumberasitappearsontheMedicaidIdentificationcard.Example:A123456.
2.Patient'sName
Required
Enterthemember'slastname,firstname,andmiddleinitial.
3.Patient'sDateofBirth/Sex
Required
Enterthemember'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedate,andtwo(2)digitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexofthemember.
4.Insured'sName
Conditional
CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sfulllastname,firstname,andmiddleinitial.Iftheinsuredusedalastnamesuffix(e.g.,Jr,Sr),enteritafterthelastnameandbeforethefirstname.
5.Patient'sAddress
NotRequired
6.Patient'sRelationshiptoInsured
Conditional
Completeifthememberiscoveredbyacommercialhealthinsurancepolicy.Placean"X"intheboxthatidentifiesthemember'srelationshiptothepolicyholder.
7.Insured'sAddress
NotRequired
8.ReservedforNUCCUse
NotRequired
9.OtherInsured'sName
Conditional
Iffield11dismarked"YES",entertheinsured'slastname,firstnameandmiddleinitial.
9a.OtherInsured'sPolicyorGroupNumber
Conditional
Iffield11dismarked"YES",enterthepolicyorgroupnumber.
9b.ReservedforNUCCUse
9c.ReservedforNUCCUse
9d.InsurancePlanorProgramName
Conditional
Iffield11Dismarked"YES",entertheinsuranceplanorprogramname.
10a-c.Ispatient'sconditionrelatedto?
Conditional
Whenappropriate,placean"X"inthecorrectboxtoindicatewhetheroneormoreoftheservicesdescribedinfield24areforaconditionorinjurythatoccurredonthejob,asaresultofanautoaccidentorother.
10d.ReservedforLocalUse
11.Insured'sPolicy,GrouporFECANumber
Conditional
CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'spolicynumberasitappearsontheIDcard.Onlycompleteiffield4iscompleted.
11a.Insured'sDateofBirth,Sex
Conditional
CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwodigitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexoftheinsured.
11b.OtherClaimID
NotRequired
11c.InsurancePlanNameorProgramName
NotRequired
11d.IsthereanotherHealthBenefitPlan?
Conditional
Whenappropriate,placean"X"inthecorrectbox.Ifmarked"YES",complete9,9aand9d.
12.Patient'sorAuthorizedPerson'ssignature
Required
Enter"SignatureonFile","SOF",orlegalsignature.Ifthereisnosignatureonfile,leaveblankorenter"NoSignatureonFile".Enterthedatetheclaimformwassigned.
13.Insured'sorAuthorizedPerson'sSignature
NotRequired
14.DateofCurrentIllnessInjuryorPregnancy
Conditional
Completeifinformationisknown.Enterthedateofillness,injuryorpregnancy,(dateofthelastmenstrualperiod)usingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwodigitsfortheyear.Example:070114forJuly1,2014.Entertheapplicablequalifiertoidentifywhichdateisbeingreported.431-OnsetofCurrentSymptomsorIllness484-LastMenstrualPeriod
15.OtherDateNot
NotRequired
16.DatePatientUnabletoWorkinCurrentOccupation
NotRequired
17.NameofReferringPhysician
Conditional
17b.NPIofReferringPhysician
Required
RequiredinaccordancewithProgramRule8.125.8.A
18.HospitalizationDatesRelatedtoCurrentService
NotRequired
19.AdditionalClaimInformation
Conditional
20.OutsideLab?$Charges
Conditional
Completeifalllaboratoryworkwasreferredtoandperformedbyanoutsidelaboratory.Ifthisboxischecked,nopaymentwillbemadetothephysicianforlabservices.Donotcompletethisfieldifanylaboratoryworkwasperformedintheoffice.Practitionersmaynotrequestpaymentforservicesperformedbyanindependentorhospitallaboratory.
21.DiagnosisorNatureofIllnessorInjury
Required
Enteratleastone(1)butnomorethan12diagnosiscodesbasedonthemember'sdiagnosis/condition.EnterapplicableICD-10code:Z33.1orZ39.2dependingontheprocedurecodebilled.
22.MedicaidResubmissionCode
Conditional
Listtheoriginalreferencenumberforresubmittedclaims.Whenresubmittingaclaim,entertheappropriatebillfrequencycodeintheleft-handsideofthefield.7-Replacementofpriorclaim8-Void/CancelofpriorclaimThisfieldisnotintendedforusefororiginalclaimsubmissions.
23.PriorAuthorization
NotRequired
PriorAuthorizationEnterthesix(6)-characterpriorauthorizationnumberfromtheapprovedPriorAuthorizationRequest(PAR).Donotcombineservicesfrommorethanone(1)approvedPARonasingleclaimform.DonotattachacopyoftheapprovedPARunlessadvisedtodosobytheauthorizingagentorthefiscalagent.
24.ClaimLineDetail
Information
Thepaperclaimformallowsentryofuptosix(6)detailedbillinglines.Fields24Athrough24Japplytoeachbilledline.Donotentermorethansixlinesofinformationonthepaperclaim.Ifmorethansix(6)linesofinformationareentered,theadditionallineswillnotbeenteredforprocessing.Eachclaimformmustbefullycompleted(totaled).Donotfilecontinuationclaims(e.g.,Page1of2).
24A.DatesofService
Required
Thefieldaccommodatestheentryoftwodates:a"From"dateofservicesanda"To"dateofservice.Enterthedateofserviceusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:010119forJanuary1,2019.
From
To
01
01
19
SingleDateofService:Enterthesix(6)-digitdateofserviceinthe"From"field.Completionofthe"To"fieldisnotrequired.Donotspreadthedateentryacrossthetwofields.Spanbilling:Notpermitted.Alldatesofservicemusthavetheirowndetailedlineitemontheclaim.
24B.PlaceofService
Required
EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.
02
TelehealthProvidedOtherthaninPatient’sHome
03
School
04
HomelessShelter
05
IHSFree-StandingFacility
06
Provider-BasedFacility
07
Tribal638Free-Standing
08
Tribal638Provider-Based
09
Prison/CorrectionalFacility
10
TelehealthProvidedinPatient’sHome
11
Office
12
Home
19
MobileUnit
20
UrgentCareFacility
21
InpatientHospital
22
OutpatientHospital
23
EmergencyRoomHospital
25
BirthingCenter
50
FederallyQualifiedHealthCenter
53
CommunityMentalHealthCenter
55
ResidentialTreatmentFacility
57
Non-residentialSubstanceAbuseTreatmentFacility
71
State-LocalPublicHealthClinic
72
RuralHealthClinic
24C.EMG
Conditional
Entera"Y"forYESorleaveblankforNOinthebottom,unshadedareaofthefieldtoindicatetheserviceisrenderedforalife-threateningconditionoronethatrequiresimmediatemedicalintervention.
24D.Procedures,Services,orSupplies
Required
EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.EitherT1032orT1033.AllproceduresmustbeidentifiedwithcodesinthecurrenteditionofPhysiciansCurrentProceduralTerminology(CPT).CPTisupdatedannually.HCPCSLevelIICodesThecurrentMedicarecodingpublication(forMedicarecrossoverclaimsonly).OnlyapprovedcodesfromthecurrentCPTorHCPCSpublicationswillbeaccepted.
24D.Modifier
Conditional
Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofourmodifiersmaybeenteredwhenusingthepaperclaimform.
FQ-Theservicewasfurnishedusingaudio-onlycommunicationtechnology.
FR-Thesupervisingpractitionerwaspresentthroughtwo-way,audio/videocommunicationtechnology.
93-SynchronousTelemedicineServiceRenderedViaTelephoneorOtherReal-TimeInteractive-Audio-Only
95-SynchronousTelemedicineServiceRenderedViaaReal-TimeInteractiveAudioandVideoTelecommunicationsSystem
24E.DiagnosisPointer
Required
Enterthediagnosiscodereferenceletter(A-L)thatrelatesthedateofserviceandtheproceduresperformedtotheprimarydiagnosis.Atleastone(1)diagnosiscodereferencelettermustbeentered.Whenmultipleservicesareperformed,theprimaryreferenceletterforeachserviceshouldbelistedfirst,otherapplicableservicesshouldfollow.Thisfieldallowsfortheentryoffour(4)charactersintheunshadedarea.
24F.$Charges
Required
Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.SomeCPTprocedurecodesaregroupedwithotherrelatedCPTprocedurecodes.Whenmorethanoneprocedurefromthesamegroupisbilled,specialmultiplepricingrulesapply.Thebaseprocedureistheprocedurewiththehighestallowableamount.ThebasecodeisusedtodeterminetheallowableamountsforadditionalCPTsurgicalprocedureswhenmorethanoneprocedurefromthesamegroupingisperformed.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColorado-coveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-payorcommercialinsurancepaymentsfromtheusualandcustomarycharges.
24G.DaysorUnits
Required
Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.
24H.EPSDT/FamilyPlan
Conditional
EPSDT(shadedarea)ForEarly&PeriodicScreening,Diagnosis,andTreatmentrelatedservices,entertheresponseintheshadedportionofthefieldasfollows:AV-Available-NotUsedS2-UnderTreatmentST-NewServiceRequestedNU-NotUsedFamilyPlanning(unshadedarea)IftheserviceisFamilyPlanning,suchasforcontraceptionorsterilization,enter"Y"forYESor"N"forNOinthebottom,unshadedareaofthefield.
24I.IDQualifier
NotRequired
24J.RenderingProviderID#
Required
Intheshadedportionofthefield,entertheNPIoftheHealthFirstColoradodoulaprovidernumberassignedtotheindividualwhoactuallyperformedorrenderedthebilledservice.Thisnumbercannotbeassignedtoagrouporclinic.
25.FederalTaxIDNumber
NotRequired
26.Patient'sAccountNumber
Optional
Enterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).
27.AcceptAssignment?
Required
Theacceptassignmentindicatesthattheprovideragreestoacceptassignmentunderthetermsofthepayer'sprogram.
28.TotalCharge
Required
Enterthesumofallchargeslistedinfield24F.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.
29.AmountPaid
Conditional
EnterthetotalamountpaidbyMedicareoranyothercommercialhealthinsurancethathasmadepaymentonthebilledservices.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.
30.RsvdforNUCCUse
31.SignatureofPhysicianorSupplierIncludingDegreesorCredentials
Required
Eachclaimmustbearthesignatureoftheenrolledproviderorthesignatureofaregisteredauthorizedagent.Eachclaimmusthavethedatetheenrolledproviderorregisteredauthorizedagentsignedtheclaimform.Enterthedatetheclaimwassignedusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwodigitsfortheyear.Example:070116forJuly1,2016.Unacceptablesignaturealternatives:Claimpreparationpersonnelmaynotsigntheenrolledprovider'sname.Initialsarenotacceptableasasignature.Typedorcomputerprintednamesarenotacceptableasasignature."Signatureonfile"notationisnotacceptableinplaceofanauthorizedsignature.
32.ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#
Required
Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCodeIftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.
33.BillingProviderInfo&Ph#
Required
Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCode
33a-NPINumber
Required
33b-OtherID#
IftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
83ef203d6affc5d4e8973cd8f37bdac01359d9b1ca00d1e5450265ecd81848f5
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