Provider of Service or Supplier Information (Fields 14-33)
Field Number : 14
Field Description : Date of current illness, injury or pregnancy
Data Type : Not required
Instructions : Not applicable.
Field Number : 15
Field Description : If patient has had same or similar illness, give first date
Data Type : Not required
Instructions : Not applicable.
Field Number : 16
Field Description : Dates patient unable to work in current occupation
Data Type : Conditional
Instructions : Required if the patient is eligible for disability or worker's compensation benefits due to this illness. Enter the “From” and “To” dates the patient was unable to work in MMDDYY or MMDDCCYY format.
Field Number : 17
Field Description : Name of referring physician or other source
Data Type : Conditional
Instructions : Enter the name of the referring physician or other source if applicable.
Field Number : 17a
Field Description : ID number of referring physician
Data Type : Conditional
Instructions : The CMS-assigned UPIN of the referring or ordering physician listed in Field 17. Enter only the seven-digit base number and the one-digit check digit.
NOTE: The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifier indicating what the number represents should be reported in the qualifier field to the immediate right of 17a. The NUCC defines the following qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
• 0B – State license number
• 1B – Blue Shield provider number
• 1C – Medicare provider number
• 1D – Medicaid provider number
• 1G – Provider UPIN number
• 1H – CHAMPUS identification number
• EI – Employer’s identification number
• G2 – Provider commercial number
• LU – Location number
• N5 – Provider plan network identification number
• SY – Social Security number (The Social Security number may not be used for Medicare)
• X5 – State industrial accident provider number
• ZZ – Provider taxonomy
Field Number : 17b
Field Description : NPI
Data Type : Required
Instructions : Enter the NPI of the referring or ordering physician listed in item 17 as soon as it is available. The NPI may be reported as of October 1, 2006.
NOTE: Field 17a and / or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.
Field Number : 18
Field Description : Hospitalization dates related to current services
Data Type : Conditional
Instructions : Required if this claim includes charges for services rendered during an inpatient admission. Enter dates in MMDDYY format.
Field Number : 19
Field Description : Reserved for local use
Data Type : Conditional
Instructions : If billing for intensive outpatient programs, please write "IOP" in this space.
Field Number : 20
Field Description : Outside lab/charges
Data Type : Conditional
Instructions : Enter if lab tests performed and billed on this claim were processed by a lab outside the provider’s premises.
Field Number : 21.1-4
Field Description : Diagnosis or nature of illness or injury
Data Type : Required
Instructions : Enter a valid ICD-9 diagnosis code, coding to the highest level of specificity (include fourth and fifth digits if applicable) that describes the principal diagnosis for services rendered.
Enter up to four codes in priority order (primary, secondary, etc.)
Field Number : 22
Field Description : Medicaid resubmission code/original reference number
Data Type : Conditional
Instructions : List the original reference (claim) number for resubmitted claims.
Field Number : 23
Field Description : Prior authorization number
Data Type : Not required
Instructions : Not applicable.
Field Number : 24a
Field Description : Dates of service
Data Type : Required
Instructions : Enter “From” and “To” dates of service in MMDDYY or MMDDCCYY format. Line items can include no more than two dates of service for the same procedure code. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column C.
Field Number : 24b
Field Description : Place of service
Data Type : Required
Instructions : Enter the appropriate place of service code.
Field Number : 24c
Field Description : EMG
Data Type : Not required
Instructions : Not applicable.
Field Number : 24d
Field Description : Procedures, services or supplies CPT/HCPCS
Data Type : Required
Instructions : Enter a valid CPT or HCPCS code for each service rendered.
Field Number : 24d
Field Description : Modifier
Data Type : Conditional
Instructions : Enter a valid CPT or HCPCS code modifier for each service entered.**
HIPAA: Billing Code Modifiers
** When submitting a CPT or HCPC code with a modifier, it is critical that the modifier be placed in its appropriate allocation. HIPAA allows up to four (4) modifiers to be used. The order of the modifiers has a particular meaning. The order of the modifiers is found below:
Modifier ONE: This field is dedicated for modifiers that affect or define the service (e.g., TG modifier to identify a ‘complex high level of care’)
Modifier TWO: This field is dedicated for modifiers that identify pricing (e.g., HA modifier to identify ‘child/adolescent’ or HN modifier to identify ‘bachelors level’)
Modifier THREE & FOUR: These fields are dedicated for modifiers that identify statistics (e.g., HV ‘funded by State Addictions Agency’)
If you have any questions regarding the placement of Modifiers, please contact your Regional Provider Relations office for instructions.
Field Number : 24e
Field Description : Diagnosis pointer
Data Type : Conditional
Instructions : 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. When multiple services are performed, the primary reference number for each service, either a 1, 2, 3 or 4, is shown. Do not enter the ICD-9 diagnosis code.
Field Number : 24f
Field Description : Charges
Data Type : Required
Instructions : Enter the provider’s billed charges for each service.
Field Number : 24g
Field Description : Days or units
Data Type : Required
Instructions : Enter the appropriate number of units or days that correspond to the “From” and “To” dates indicated in Field 24a.
Field Number : 24h
Field Description : EPSDT family plan
Data Type : Conditional
Instructions : If service was rendered as part of or in response to an EPSDT panel, mark an "X" in this block.
Field Number : 24i
Field Description : ID Qual.
Data Type : Conditional
Instructions : If the provider does not have an NPI, enter the appropriate qualifier and identifying number in the shaded area. There will always be providers who do not have an NPI and will need to report non-NPI identifiers on their claim forms. The qualifiers will indicate the non-NPI number being reported.
Field Number : 24j
Field Description : Rendering Provider ID.#
Data Type : Required
Instructions : Enter the NPI number in the un-shaded area of the field.
Field Number : 25
Field Description : Federal Tax ID number and type:
• Social Security Number or
• Employer Identification Number
Data Type : Required
Instructions : Enter the nine-digit Employee Identification Number (EIN) or Social Security Number under which payment for services is to be made for reporting earnings to the IRS. Enter an "X" in the appropriate box that identifies the type of ID number used for services rendered.
Field Number : 26
Field Description : Patient's account number
Data Type : Optional
Instructions : Enter the unique number assigned by the provider for the patient. If entered, the patient account number will be returned to the provider on the Provider Summary Voucher.
Field Number : 27
Field Description : Accept assignment?
Data Type : Required
Instructions : Enter an "X" in the appropriate box.
Field Number : 28
Field Description : Total charge
Data Type : Required
Instructions : Enter the total charge for this claim. This is the total of all charges for each service noted in Field 24f.
Field Number : 29
Field Description : Amount paid
Data Type : Conditional
Instructions : Enter the total amount paid by the patient for services billed on this claim.
Field Number : 30
Field Description : Balance due
Data Type : Conditional
Instructions : Enter the total balance due for the services less any amount entered in Field 29.
Field Number : 31
Field Description : Signature of physician or supplier including degrees or credentials
Data Type : Required
Instructions : Signature of physician or supplier including degree(s) or credentials and date of signature. NOTE: The person rendering care must sign and indicate licensure level.
Field Number : 32
Field Description : Name and address of facility where services were rendered
Data Type : Required
Instructions : Enter name and address where services are rendered.
Field Number :32a
Field Description : a.
Data Type : Required
Instructions : Enter the NPI of the service facility
Field Number : 32b
Field Description : b.
Data Type : Not Required
Instructions : Not Applicable
Field Number : 33
Field Description : Physician’s/supplier's billing: name, address, zip code and phone number
Data Type : Required
Instructions : Enter the appropriate billing information.
Field Number : 33a
Field Description : PIN number
Data Type : Required
Instructions : Enter the NPI of the billing provider or group.
Field Number : 33b
Field Description : Group number
Data Type : Not Required
Instructions : Not Applicable after May 23, 2007
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