Va. DMAS Hospice Provider Manual ch. V, Instructions For Use Of The CMS-1500 (02-12), Billing Form

Providers typically use Direct Data Entry (DDE), however, the CMS-1500 (02-12) form

must be used in those instances where DMAS has requested the use of the paper form.

The following instructions have numbered items corresponding to fields on the CMS-1500

(02-12).

SPECIAL NOTE: The provider number in locator 24J must be the same in locator 33

unless the Group/Billing Provider relationship has been established and approved by

DMAS for use.

1

Locator REQUIRED

Instructions Enter an "X" in the MEDICAID box for the

Medicaid Program. Enter an “X” in the OTHER box for Temporary Detention

Order (TDO) or Emergency Detention Order (EDO).

1a

REQUIRED Insured's I.D. Number - Enter the 12-digit Virginia Medicaid

identification number for the member receiving the service.

2

REQUIRED Patient's Name - Enter the name of the member receiving the

service.

3

NOT REQUIRED

Patient's Birth Date

4

NOT REQUIRED

Insured's Name

5

NOT REQUIRED

Patient's Address

6

NOT REQUIRED

Patient Relationship to Insured

7

NOT REQUIRED

Insured's Address

8

NOT REQUIRED

Reserved for NUCC Use

9

NOT REQUIRED

Other Insured's Name

9a

NOT REQUIRED

Other Insured's Policy or Group Number

9b

NOT REQUIRED

Reserved for NUCC Use

9c NOT REQUIRED Reserved for NUCC Use

9d NOT REQUIRED Insurance Plan Name or Program Name

10 REQUIRED Is Patient's Condition Related To: - Enter an "X" in the

appropriate box.

a.

Employment?

b.

Auto accident

c.

Other Accident? (This includes schools, stores,

assaults, etc.)

NOTE: The state postal code should be entered if known.

10d Conditional Claim Codes (Designated by NUCC)

Enter “ATTACHMENT” if documents are attached to the claim form.

11 NOT REQUIRED

Insured's Policy Number or FECA Number

11a

NOT REQUIRED

Insured's Date of Birth

11b NOT REQUIRED Other Claim ID

11c REQUIRED If applicable, Insurance Plan or Program Name

If applicable, providers that are billing for non-Medicaid MCO copays only – please

insert “HMO Copay.

11d

REQUIRED if applicable

Is there another health benefit plan? Providers

should only check Yes if there is other third party coverage.

12

NOT REQUIRED

Patient’s or Authorized Person’s signature

13

NOT REQUIRED

Insured or Authorized Person’s signature

14

REQUIRED if applicable Date of current illness, injury, or pregnancy. Enter date

MM DD YY. Enter Qualifier 431 – Onset of current symptoms or illness.

15

NOT REQUIRED

Other date

16

NOT REQUIRED

Dates patient unable to work in current occupation

17

REQUIRED if applicable

Name of referring physician or other source

17a

REQUIRED

ID number of referring physician. The qualifier ZZ may be

entered if the provider taxonomy code is needed to adjudicate the claim.

17b REQUIRED

ID number of the referring physician. Enter the National

Provider Identifier of the referring physician.

18 NOT REQUIRED

Hospitalization Dates Related to Current Services

19 REQUIRED if applicable

Additional claim information. Enter the CLIA #.

20 NOT REQUIRED Outside lab.

21 REQUIRED

Diagnosis or nature of illness or injury. Enter the

appropriate ICD diagnosis code, which describes the nature

of the illness or injury for which the service was rendered in

locator 24E. Note: Line ‘A’ field should be the

Primary/Admitting diagnosis followed by the next highest

level of specificity in lines B-L.

Note: ICD Ind. -OPTIONAL

0=ICD-10-CM – Dates of service 10/1/15 and after

22

REQUIRED if applicable Resubmission Code – Original Reference Number.

Required for adjustment and void. See the instructions

for Adjustment and Void Invoices.

23

REQUIRED if applicable Service authorization (SA) Number – Enter the PA

number for approved services that require a service authorization.

NOTE: The locators 24A thru 24J have been divided into open areas and a shaded line

area. The shaded area is ONLY for supplemental information. DMAS has given

instructions for the supplemental information that is required when needed for DMAS

claims processing. ENTER REQUIRED INFORMATION ONLY.

24a lines 1-6 open area

REQUIRED Dates of Service - Enter the from and thru

dates in a 2-digit format for the month, day and year (e.g., 01/01/14).

DATES MUST BE WITHIN THE SAME MONTH

24a lines 1-6 red shaded REQUIRED if applicable DMAS requires the use of qualifier

‘TPL’. This qualifier is to be used whenever an actual

payment is made by a third party payer. The ‘TPL’ qualifier is

to be followed by the dollar/cents amount of the payment by

the third party carriers. Example: Payment by other carrier is

$27.08; red shaded area would be filled as TPL27.08. No

spaces between qualifier and dollars. No $ symbol but the

decimal between dollars and cents is required.

DMAS requires the use of the qualifier ‘N4’. This qualifier is to be used for the National

Drug Code (NDC) whenever a HCPCS drug related code is submitted in 24D to DMAS.

No spaces between the qualifier and the NDC number.

NOTE: The unit of measurement qualifier code is followed by the metric decimal quantity

Unit of Measurement Qualifier Codes: F2 – International Units

GR – Gram ML – Milliliter UN – Unit

Examples of NDC quantities for various dosage forms as follows:

• Tablets/Capsules – bill per UN

• Oral Liquids – bill per ML

• Reconstituted (or liquids) injections – bill per ML

• Non-reconstituted injections (I.E. vial of Rocephin powder) – bill as UN (1 vial = 1

unit)

• Creams, ointments, topical powders – bill per GR

• Inhalers – bill per GR

BILLING EXAMPLES:

TPL, NDC and UOM submitted: TPL3.50N412345678901ML1.0

NDC, UOM and TPL submitted: N412345678901ML1.0TPL3.50

NDC and UOM submitted only: N412345678901ML1.0

TPL submitted only:

TPL3.50

Note: Enter only TPL, NDC and UOM information in the supplemental shaded area.

(see billing examples)

All supplemental information is to be left justified.

SPECIAL NOTE: DMAS will set the coordination of benefit code based on information

supplied as followed:

• If there is nothing indicated or ‘NO’ is checked in locator 11d, DMAS will set that

the patient had no other third party carrier. This relates to the old coordination of

benefit code 2.

• If locator 11d is checked ‘YES’ and there is nothing in the locator 24a red

shaded line; DMAS will set that the third party carrier was billed and made no

payment. This relates to the old coordination of benefit code 5. An

EOB/documentation must be attached to the claim to verify nonpayment.

• If locator 11d is checked ‘YES’ and there is the qualifier ‘TPL’ with payment

amount (TPL15.50), DMAS will set that the third party carrier was billed and

payment made of $15.50. This relates to the old coordination of benefit code 3.

24b open area

REQUIRED Place of Service - Enter the 2-digit CMS code, which

describes where the services were rendered.

24c open area

REQUIRED if applicable Emergency Indicator - Enter either ‘Y’ for

YES or leave blank. DMAS will not accept any other indicators

for this locator.

24d open area

REQUIRED Procedures, Services or Supplies – CPT/HCPCS –

Enter the CPT/HCPCS code that describes the procedure rendered

or the service provided. Modifier - Enter the appropriate

CPT/HCPCS modifiers if applicable.

24e open area

REQUIRED Diagnosis Code - Enter the diagnosis code reference

letter A-L (pointer) as shown in Locator 21 to relate the date of

service and the procedure performed to the primary diagnosis. The

primary diagnosis code reference letter for each service should be

listed first. NOTE: A maximum of 4 diagnosis code reference

letter pointers should be entered. Claims with values other than

A-L in Locator 24-E or blank may be denied.

24f open area

REQUIRED Charges - Enter your total usual and customary

charges for the procedure/services.

24g open area

REQUIRED Days or unit. Enter the number of times the

procedure, service, or item was provided during the service period.

24h open area

REQUIRED if applicable. EPSDT or Family Planning - Enter the

appropriate indicator. Required only for EPSDT or family planning

services.

1. Early and Periodic, Screening, Diagnosis and Treatment Program

Services

2. Family Planning Service

24I REQUIRED

NPI – this is to identify that it is an NPI that is in locator 24J

24I red shaded

REQUIRED if applicable. ID QUALIFIER –The qualifier ‘ZZ’ is

entered to identify the rendering provider taxonomy code.

24J open

REQUIRED if applicable. Rendering provider ID# - Enter the 10

digit NPI number for the provider that performed/rendered the care.

24J red shaded

REQUIRED if applicable. Rendering provider ID# - The qualifier

‘ZZ’ is entered to identify the provider taxonomy code.

25

NOT REQUIRED

Federal Tax I.D. Number

26

REQUIRED Patient's Account Number – Up to FOURTEEN alpha-numeric characters are acceptable.

27

NOT REQUIRED

Accept Assignment

28

REQUIRED Total Charge - Enter the total charges for the services

in 24F lines 1-6

29

REQUIRED if applicable. Amount Paid – For personal care and

waiver services only – enter the patient pay amount that is due from

the patient. NOTE: The patient pay amount is taken from services

billed on 24A - line 1. If multiple services are provided on same date

of service, then another form must be completed since only one line

can be submitted if patient pay is to be considered in the

processing of this service.

30

NOT REQUIRED. Reserved for NUCC use.

31

REQUIRED. Signature of Physician or Supplier Including Degrees

Or Credentials - The provider or agent must sign and date the

invoice in this block.

32

REQUIRED if applicable. Service Facility Location Information –

Enter the name as first line, address as second line, city, state and

9 digit zip code as third line for the location where the services were

rendered. NOTE: For physician with multiple office locations, the

specific Zip code must reflect the office location where services

given. Do NOT use commas, periods or other punctuations in the

address. Enter space between city and state. Include the hyphen for

the 9 digit zip code.

32a open

REQUIRED if applicable. NPI # - Enter the 10 digit NPI number of

the service location.

32b red shaded

REQUIRED if applicable. Other ID#: - The qualifier of ‘ZZ’ is

entered to identify the provider taxonomy code.

33

REQUIRED. Billing Provider Info and PH # - Enter the billing name

As first line, address as second line, city, state and 9-digit zip code

as third line. This locator is to identify the provider that is requesting

to be paid.

NOTE: Do NOT use commas, periods or other punctuations in the

address. Enter space between city and state. Include the hyphen for

the 9 digit zip code. The phone number is to be entered in the area

to the right of the field title. Do not use hyphen or space as

separator within the telephone number.

33a open

REQUIRED NPI – Enter the 10 digit NPI number of the billing

provider.

33b red shaded

REQUIRED if applicable. Other Billing ID - The qualifier ‘ZZ’ is

entered to identify the provider taxonomy code.

NOTE: DO NOT use commas, periods, space, hyphens or other

punctuations between the qualifier and the number.