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CO HCPF Non-Emergent Medical Transportation (NEMT) Billing Manual — CMS 1500 Paper Claim Reference Table

CMS1500PaperClaimReferenceTable

activein force · 2026-07-26 – presentas-observed

Thefollowingpaperformreferencetableshowsrequired,optional,andconditionalfieldsanddetailedfieldcompletioninstructionsfortheEPSDTclaimform.

CMSFieldNumberandLabel

Fieldis?

Instructions

1.InsuranceType

Required

Placean"X"intheboxmarkedasMedicaid.

1a.Insured'sIDNumber

Required

Enterthemember'sHealthFirstColoradoseven-digitHealthFirstColoradoIDnumberasitappearsontheHealthFirstColoradoIdentificationcard.Example:A123456.

2.Patient'sName

Required

Enterthemember'slastname,firstname,andmiddleinitial.

3.Patient'sDateofBirth/Sex

Required

Enterthemember'sbirthdateusingtwodigitsforthemonth,twodigitsforthedate,andtwodigitsfortheyear.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.ClientRelationshiptoInsured

Conditional

Completeifthememberiscoveredbyacommercialhealthcareinsurancepolicy.

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

11a.Insured'sDateofBirth,Sex

NotRequired

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sbirthdateusingtwodigitsforthemonth,twodigitsforthedateandtwodigitsfortheyear.Example:070114forJuly1,2014.PlaceanX"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

NotRequired

15.OtherDateNot

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Conditional

17b.NPIofReferringPhysician

Conditional

18.HospitalizationDatesRelatedtoCurrentService

NotRequired

19.AdditionalClaimInformation

Conditional

Whenapplicable,enterthewords"TRANSPORTCERT"tocertifythatyouhaveatransportationcertificateortripsheetonfileforthisservice.

20.OutsideLab?$Charges

NotRequired

21.DiagnosisorNatureofIllnessorInjury

Required

Enteratleastonebutnomorethantwelvediagnosiscodesbasedonthemember'sdiagnosis/condition.EnterapplicableICD-10indicator.NEMTEnterdiagnosiscodeR68.89.

22.MedicaidResubmissionCode

Conditional

Listtheoriginalreferencenumberforresubmittedclaims.Whenresubmittingaclaim,entertheappropriatebillfrequencycodeintheleft-handsideofthefield.7-Replacementofpriorclaim8-Void/CancelofpriorclaimThisfieldisnotintendedforusefororiginalclaimsubmissions.

23.PriorAuthorization

NotRequired

24.ClaimLineDetail

Information

Thepaperclaimformallowsentryofuptosixdetailedbillinglines.Fields24Athrough24Japplytoeachbilledline.Donotentermorethansixlinesofinformationonthepaperclaim.Ifmorethansixlinesofinformationareentered,theadditionallineswillnotbeenteredforprocessing.Eachclaimformmustbefullycompleted(totaled).Donotfilecontinuationclaims(e.g.,Page1of2).

24A.DatesofService

Required

Thefieldaccommodatestheentryoftwodates:a"From"dateofservicesanda"To"dateofservice.Enterthedateofserviceusingtwodigitsforthemonth,twodigitsforthedateandtwodigitsfortheyear.Example:010116forJanuary1,2016.

From

SingleDateofServiceEnterthesix-digitdateofserviceinthe"From"field.CompletionoftheTofieldisnotrequired.Donotspreadthedateentryacrossthetwofields.SpanBillingisnotallowedforNEMT.

24B.PlaceofService

Required

EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.

Transportation-Land

Transportation-AirorWater

24C.EMG

Conditional

Enteran"N"orleaveblankforNOinthebottom,unshadedareaofthefieldtoindicatetheservicewasnon-emergentmedicaltransportation.

24D.Procedures,Services,orSupplies

Required

EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.OnlyapprovedcodesfromthecurrentCPTorHCPCSpublicationswillbeaccepted.

24D.Modifier

NotRequired

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofourmodifiersmaybeenteredwhenusingthepaperclaimform.NEMTOnlyA0110mayrequireamodifier.RefertoTransportationHCPCScodes.

24E.DiagnosisPointer

Required

Enterthediagnosiscodereferenceletter(A-L)thatrelatesthedateofserviceandtheproceduresperformedtotheprimarydiagnosis.Atleastonediagnosiscodereferencelettermustbeentered.Whenmultipleservicesareperformed,theprimaryreferenceletterforeachserviceshouldbelistedfirst,otherapplicableservicesshouldfollow.Thisfieldallowsfortheentryof4charactersintheunshadedarea.

24F.$Charges

Required

Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColorado-coveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-payorcommercialinsurancepaymentsfromtheusualandcustomarycharges.

24G.DaysorUnits

Required

Enterthenumberofunitsprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.

24H.EPSDT/FamilyPlan

NotRequired

24I.IDQualifier

NotRequired

24J.RenderingProviderID#

Required

Intheshadedportionofthefield,entertheNPIorProviderIDoftheHealthFirstColoradoproviderwhoactuallyperformedorrenderedthebilledservice.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.Enterthedatetheclaimwassignedusingtwodigitsforthemonth,twodigitsforthedateandtwodigitsfortheyear.Example:070116forJuly1,2016.

32.32-ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#

Required

Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCodeIftheProviderTypeisnotabletoobtainanNPI,entertheeight-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

33.BillingProviderInfo&Ph#

Required

Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCode

33a-NPINumber

Required

33b-OtherID#

IftheProviderTypeisnotabletoobtainanNPI,entertheeight-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

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RefertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageundertheAppendicesdrop-downformoreinformationontimelyfilingpolicy,includingtheresubmissionrulesfordeniedclaims.

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Formoreinformationonprogramintegrityandcompliance,refertotheProgramIntegrityandCompliancesectionoftheGeneralInformationManualontheBillingManualswebpage.

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RevisionDate

Section/Action

Madeby

12/1/2016

ManualrevisedforinterChangeimplementation.Formanualrevisionspriorto12/01/2016,pleaserefertoArchive.

HPE

12/27/2016

UpdatesbasedonColoradoiCStageIIProviderBillingManualCommentLogv0_2.xlsx

HPE

1/10/2017

UpdatesbasedonColoradoiCStageProviderBillingManualCommentLogv0_3.xlsx

HPE

1/19/2017

UpdatesbasedonColoradoiCStageProviderBillingManualCommentLogv0_4.xlsx

HPE

1/26/2017

UpdatesbasedonDepartment1/20/2017approvalemail

HPE

12/12/2017

ManualrevisedtoseparateNEMTandEMTservices.ChangedthenametoNEMTBillingManual.Updatesmadethroughouttoalignwithcurrentpoliciesandbillingrules.

HCPF

4/12/2018

CorrectedWheelchairVanprocedurecode

HCPF

6/22/2018

UpdatedbillingandtimelytopointtoGeneralBillingmanual

HCPF

6/28/2018

Editedlink,editedtimely

HCPF

11/15/2018

Clarifiedinterfacilitytransfers,9-1-1responsecalls,andunitlimitsforancillaryservices.Removedcrossoverclaimexample.AddedUrgentTransportation.

HCPF

12/21/2018

Clarificationtosignaturerequirements

HCPF

3/18/2019

Clarificationtosignaturerequirements

HCPF

7/11/2019

UpdatedAppendiceslinksandverbiage

DXC

11/20/2019

Changedspecifictermto"transportationvendor"

DXC

12/9/2019

UpdatedSDEentrytoIntelliRide,addedlinkforprovidercontacts

HCPF

12/19/2019

Convertedtowebpage

HCPF

9/14/2020

AddedLinetoBox32undertheCMS1500PaperClaimReferenceTable

HCPF

12/17/2020

UpdatedSDEentrytoreflectIntelliRideasthestatewidebroker

HCPF

12/29/2020

Addedinformationonmodifiersforbillingmultipledailytripspermember

HCPF

6/30/2021

AddedinformationonSDEserviceandproviderbilling

HCPF

7/22/2021

Addedverbiageformultipletripsbymemberinsingleday

HCPF

8/18/2021

Removedreferencestonow-defunctwebpage

HCPF

8/14/2023

RemovedreferencestoPUCandMCTpermitswherenecessaryasitisnolongerarequirementpursuanttoHB21-1206

HCPF

2/21/2024

Addedbillingrulesandinformationfor25mileorlongerNEMTrides

HCPF

6/17/2024

AddedclarificationaroundEPSDTpoliciesandreferences,credentialing,returntripswithoutthememberpresent,tripsrelatingtoschoolservices,clarificationaroundbillingformulti-loadedvehicles,25-mileverificationformlink

HCPF

7/1/2024

UpdatedEPSDTlanguage.Clarifiedthat25-mileverificationformcanbesignedbythemember’sreferringprovider.

HCPF

9/9/2024

AddedTripstoPharmaciesinfo.AddedStandardForms(TripLog).Updated25-mileformproviderinfoforcompletingtheform.AddedChildAccompanimentlanguage.Clarifiedpharmacytripcoverage.

HCPF

01/31/25

AddedProviderResponsibilitiesforNEMTprovidersoutsidethebrokerserviceareaincludingcheckingeligibilityandclaimsubmissioninformation,inaccordancewithpreviouslypublishedmemoHCPFOM-074.

HCPF

04/10/25

AddedimportantremindertoAncillaryServicesfortravelingwithminorchildren.

HCPF

05/27/25

AddedNEMTprovidereligibilityandverificationresponsibilitiesthatreferenceOperationalMemo25-028.AddedHCPCScodingchangesformobility/ambulatoryvehiclesandtaxicabforA0425,S0215andS0209effectiveJuly1,2025

HCPF

08/13/2025

Addedruralmileageeditinfoeffective9/30/25.AddedNEMTprovidersmaynotbillNEMTtheymustusemileagereimbursement.Addedinformationaboutthememberpersonalvehiclemileagereimbursementpolicy.

HCPF

10/15/2025

MemberEligibilitysection,clarifiedthat“EMS-EmergencyMedicaidandReproductiveHealthProgram”benefitplancoverageisnoteligibleforNEMT.

HCPF

11/3/2025

AddedXLWheelchairbillinginfowithmodifiereffective11-1-2025.DiscontinueduseofHCPCSA0434forNEMTbenefiteffective11-1-25.

HCPF

11/12/2025

CorrectedmodifierforXLwheelchairfromU1toU9

HCPF

01/09/2026

Addedclaimsinfoforactualmodeoftransportandlevelofmedicalneedforbillingclaims

HCPF

06/02/2026

UpdatedSDE/BrokerinfoforMediDriveeffectiveJuly1,2026,addedTNCpolicypursuanttoHB26-1328,addedmoredetailtospanbillingprohibition

HCPF

07/17/2026

AddedProgramIntegrityandCompliance

HCPF

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 61dda2ad9910ee6a492ee032c69e66d1299a23ac92531a5216db6da812cc2602

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