| physician or the provider must
either enter the information or enter "NA" (not available) if the
information is unknown;
(L) other insured's or enrollee's HMO or insurer name
(CMS-1500 (08/05), field 9d) is required if the patient is covered
by more than one health benefit plan, generally in situations described
in subsection (d) of this section. If the required data element specified
in subparagraph (Q) of this paragraph, "disclosure of any other health
benefit plans," is answered "Yes," this element is required unless
the physician or the provider submits with the claim documented proof
that the physician or the provider has made a good faith but unsuccessful
attempt to obtain from the enrollee or the insured any of the information
needed to complete this data element;
(M) whether the patient's condition is related to employment,
auto accident, or other accident (CMS-1500 (08/05), field 10) is required,
but facility-based radiologists, pathologists, or anesthesiologists
must enter "N" if the answer is "No" or if the information is not
available;
(N) if the claim is a duplicate claim, a "D" is required;
if the claim is a corrected claim, a "C" is required (CMS-1500 (08/05),
field 10d);
(O) subscriber's policy number (CMS-1500 (08/05), field
11) is required;
(P) HMO or insurance company name (CMS-1500 (08/05),
field 11c) is required;
(Q) disclosure of any other health benefit plans (CMS-1500
(08/05), field 11d) is required;
(i) if answered "Yes," then:
(I) data elements specified in subparagraphs (H) -
(L) of this paragraph are required unless the physician or the provider
submits with the claim documented proof that the physician or the
provider has made a good faith but unsuccessful attempt to obtain
from the enrollee or the insured any of the information needed to
complete the data elements in subparagraphs (H) - (L) of this paragraph;
(II) the data element specified in subparagraph (KK)
of this paragraph is required when submitting claims to secondary
payor MCCs;
(ii) if answered "No," the data elements specified
in subparagraphs (H) - (L) of this paragraph are not required if the
physician or the provider has on file a document signed within the
past 12 months by the patient or authorized person stating that there
is no other health care coverage. Although the submission of the signed
document is not a required data element, the physician or the provider
must submit a copy of the signed document to the MCC on request;
(R) patient's or authorized person's signature or a
notation that the signature is on file with the physician or the provider
(CMS-1500 (08/05), field 12) is required;
(S) subscriber's or authorized person's signature or
a notation that the signature is on file with the physician or the
provider (CMS-1500 (08/05), field 13) is required;
(T) date of injury (CMS-1500 (08/05), field 14) is
required if due to an accident;
(U) when applicable, the physician or the provider
must enter the name of the referring primary care physician, specialty
physician, hospital, or other source (CMS-1500 (08/05), field 17).
However, if there is no referral, the physician or the provider must
enter "Self-referral" or "None";
(V) if there is a referring physician noted in CMS-1500
(08/05), field 17, the physician or the provider must enter the ID
Number of the referring primary care physician, specialty physician,
or hospital (CMS-1500 (08/05), field 17a);
(W) if there is a referring physician noted in CMS-1500
(08/05), field 17, the physician or the provider must enter the NPI
number of the referring primary care physician, specialty physician,
or hospital (CMS-1500 (08/05), field 17b) if the referring physician
is eligible for an NPI number;
(X) narrative description of procedure (CMS-1500 (08/05),
field 19) is required when a physician or a provider uses an unlisted
or unclassified procedure code or an NDC code for drugs;
(Y) for diagnosis codes or nature of illness or injury
(CMS-1500 (08/05), field 21), up to four diagnosis codes may be entered.
At least one is required, but the primary diagnosis must be entered
first;
(Z) verification number (CMS-1500 (08/05), field 23)
is required if services have been verified under §19.1719 of
this title (relating to Verification for Health Maintenance Organizations
and Preferred Provider Benefit Plans). If no verification has been
provided, a prior authorization number (CMS-1500 (08/05), field 23)
is required when prior authorization is required and granted;
(AA) date(s) of service (CMS-1500 (08/05), field 24A)
is required;
(BB) place of service code(s) (CMS-1500 (08/05), field
24B) is required;
(CC) procedure/modifier code (CMS-1500 (08/05), field
24D) is required;
(DD) diagnosis code by specific service (CMS-1500 (08/05),
field 24E) is required with the first code linked to the applicable
diagnosis code for that service in field 21;
(EE) charge for each listed service (CMS-1500 (08/05),
field 24F) is required;
(FF) number of days or units (CMS-1500 (08/05), field
24G) is required;
(GG) the NPI number of the rendering physician or provider
(CMS-1500 (08/05), field 24J, unshaded portion) is required if the
rendering provider is not the billing provider listed in CMS-1500
(08/05), field 33, and if the rendering physician or provider is eligible
for an NPI number;
(HH) physician's or provider's federal tax ID number
(CMS-1500 (08/05), field 25) is required;
(II) whether assignment was accepted (CMS-1500 (08/05),
field 27) is required if assignment under Medicare has been accepted;
(JJ) total charge (CMS-1500 (08/05), field 28) is required;
(KK) amount paid (CMS-1500 (08/05), field 29) is required
if an amount has been paid to the physician or the provider submitting
the claim by the patient or subscriber, or on behalf of the patient
or subscriber or by a primary plan to comply with subparagraph (Q)
of this paragraph and as required by subsection (d) of this section;
(LL) signature of physician or provider or a notation
that the signature is on file with the MCC (CMS-1500 (08/05), field
31) is required;
(MM) name and address of the facility where services
were rendered, if other than home, (CMS-1500 (08/05), field 32) is
required;
(NN) the NPI number of the facility where services
were rendered, if other than home, (CMS-1500 (08/05), field 32a) is
required if the facility is eligible for an NPI;
(OO) physician's or provider's billing name, address,
and telephone number (CMS-1500 (08/05), field 33) is required;
(PP) the NPI number of the billing provider (CMS-1500
(08/05), field 33a) is required if the billing provider is eligible
for an NPI number; and
(QQ) provider number (CMS-1500 (08/05), field 33b)
is required if the MCC required provider numbers and gave notice of
the requirement to physicians and providers before June 17, 2003.
(3) Required form and data elements for institutional
providers. The UB-04 claim form and the data elements described in
this paragraph are required for claims filed or refiled by institutional
providers. The UB-04 claim form must be completed under the special
instructions applicable to the data elements as described by this
paragraph for clean claims filed by institutional providers.
(A) provider's name, address, and telephone number
(UB-04, field 1) are required;
(B) patient control number (UB-04, field 3a) is required;
(C) type of bill code (UB-04, field 4) is required
and must include a "7" in the fourth position if the claim is a corrected
claim;
(D) provider's federal tax ID number (UB-04, field
5) is required;
(E) statement period (beginning and ending date of
claim period) (UB-04, field 6) is required;
(F) patient's name (UB-04, field 8a) is required;
(G) patient's address (UB-04, field 9a - 9e) is required;
(H) patient's date of birth (UB-04, field 10) is required;
(I) patient's sex (UB-04, field 11) is required;
(J) date of admission (UB-04, field 12) is required
for admissions, observation stays, and emergency room care;
(K) admission hour (UB-04, field 13) is required for
admissions, observation stays, and emergency room care;
(L) type of admission (such as emergency, urgent, elective,
newborn) (UB-04, field 14) is required for admissions;
(M) point of origin for admission or visit code (UB-04,
field 15) is required;
(N) discharge hour (UB-04, field 16) is required for
admissions, outpatient surgeries, or observation stays;
Cont'd... |
