Capital PPS Exception Payments

A3-3611.7, 42 CFR 412.348

Exception payments are provided for hospitals with inordinately high levels of capital obligations. Payment is made to a hospital paid under either the fully prospective payment methodology, or the hold-harmless payment methodology. Exception payments will expire at the end of the 10-year transition period. Exception payments ensure that:

• Sole community hospitals receive 90 percent of their Medicare inpatient capital costs; 

• Urban hospitals with 100 or more beds and a disproportionate share patient percentage of at least 20.2 percent receive 80 percent of their Medicare inpatient capital costs; and 

• All other hospitals receive 70 percent of their Medicare inpatient capital costs.

Pricer adds interim exception payments to the basic capital payment, using the rate entered in positions 189-194 of the provider-specific file. The A/B MAC (A) adjusts these interim payments, as needed, at cost report settlement.

A hospital is entitled to an additional payment if its capital payments for the cost reporting period would otherwise be less than the applicable minimum payment level. The additional payment equals the difference between the applicable minimum payment level and the capital payments that the hospital would otherwise receive minus any offset amount.

A limited exception is also provided during the 10-year transition period for hospitals that experience unanticipated extraordinary circumstances that require an unanticipated major capital expenditure. Events such as a tornado, earthquake, catastrophic fire, or a hurricane are examples of extraordinary circumstances. The capital project must cost at least $5 million (net of proceeds from other payment sources such as insurance, litigation decisions and other State, local or Federal government funding programs) to qualify for this exception. An eligible hospital's minimum payment level under this exception is 85 percent of costs associated with the unanticipated capital expenditure and the applicable minimum payment level for its other Medicare inpatient capital costs.

Total estimated payments under the exception process may not exceed 10 percent of the total estimated capital prospective payments (exclusive of hold-harmless payments for old capital) for the same fiscal year.

These limited exceptions must be approved by CMS prior to payment. If approved, the A/B MAC (A) includes the limited exception payment amount per discharge in the exception field of the provider specific file.

Capital Outliers

A3-3611.8 

Total Federal PPS payments are reduced by an amount equal to anticipated outlier payments for the year to fund capital and operating outlier payments. Outlier payments apply only to the Federal portions of capital payments. Pricer calculates outlier payments. 

Pricer used a combined methodology to determine the day outlier payment rate for capital and operating day outliers (Day outliers were eliminated after FY 1997). A second combined methodology is used to determine the cost outlier payment rate for capital and operating costs. A capital or operating cost outlier is paid only if both capital and operating costs related to an admission exceed the combined outlier threshold. Pricer pays the higher of the combined total cost outlier payment or the total day outlier payment. An exception applies to a transferring hospital. A transferring hospital may be paid a cost outlier, but may not be paid a day outlier unless DRG 385 or 456 applies. The outlier computation methodology is contained in the A/B MAC (A) Pricer installation guide

Blended Payments

A3-3611.3 

Hospitals with a FY 1990 hospital-specific rate for capital below the Federal rate are paid a fully prospective capital rate based on a blend of their hospital-specific rate and the Federal rate. The payment for discharges occurring during a cost-reporting period that began in FY 1992 is based on a blend of 90 percent of the hospital-specific rate and 10 percent of the Federal rate. The payment for discharges occurring during a cost-reporting period that began in FY 1993 is based on a blend of 80 percent of the hospital-specific rate and 20 percent of the Federal rate. The Federal portion of the payment increases by 10 percent each year and the hospital-specific portions decreases by 10 percent each year, culminating in payment at 100 percent of the Federal rate in the tenth year.

Capital Payments in Puerto Rico

A3-3611.4 

A special standard rate applies to Puerto Rico. It is a combination of 50 percent of the Federal capital amount and 50 percent of the Puerto Rican capital amount. It is used in lieu of the Federal rate to compute hold harmless and fully prospective payments for PPS hospitals in Puerto Rico.

Old and New Capital

A3-3611.5 

Old capital is a hospital asset that: 

• Has been put in use for patient care on or before December 31, 1990; or 

• Has been legally committed to by an enforceable contract entered into on or before December 31, 1990, and put in patient use before October 1, 1994

All other assets are considered new for Medicare purposes.

New Hospitals

A3-3611.6 

New hospitals that open during the national 10-year transition are exempt from capital PPS payment for their first two years of operation. A new hospital is one that does not have a 12-month cost reporting period that ended on or before September 30, 1990. The new hospital exemption does not apply to:

• A new acute care hospital that operated as a PPS excluded hospital for 2 or more years before its transition to PPS; 

• A hospital which has been open more than 2 years, but has participated in Medicare fewer than 2 years;

• A hospital that closes and reopens within 2 years under the same or different ownership; or 

• A hospital that builds a new or replacement facility at the same or a new location, even if a change of ownership or new leasing arrangements are involved

A new hospital is paid 85 percent of its reasonable costs for capital during the exemption period. The hospital's second year of operation is the base period for determination of the hospital-specific rate and old capital assets. Effective with its third year of operation, the hospital is paid:

• The fully prospective methodology if the hospital-specific rate is less than the Federal rate. The A/B MAC (A) uses the blend rate applicable to the Federal FY in which the base period begins. For example, a new hospital with a hospitalspecific rate less than the Federal rate and a base year beginning in FY 1995 is paid 70 percent of its hospital-specific rate and 30 percent of the Federal rate; or 

• The hold harmless methodology if the hospital-specific rate is greater than the Federal rate. Hold harmless payments may continue for up to 8 years. They may continue beyond the first cost reporting period that begins on or after October 1, 2000.

Federal Rate

The standard Federal capital payment for FY 1992 and later years is based on the projected national average Medicare capital costs per discharge for each of the fiscal years. The Federal rate is adjusted for each hospital's case mix, day and cost outliers and wage index location. A hospital qualifies for a capital DSH adjustment if it is located in a large urban or other urban area, has at least 100 beds, and has a disproportionate share (DSH) percentage greater than 0.

The Federal rate is adjusted annually to reflect changes in these factors. 

An adjustment is also provided to the Federal rate for indirect costs of medical education of interns and residents. The A/B MAC (A) calculates the adjustment by dividing the hospital's full-time equivalent total of interns and residents by the hospital's total patient days (line 8, column 6 of worksheet S3 of the CMS Form 2552-89, minus the total of the lines 1B, 1C, 1D, and 7, divided by the number of days in the cost reporting period.) It reviews the hospital's records and makes any needed changes in the count at the end of the cost reporting period. It enters the indirect medical education adjustment ratio in positions 184-188 of the provider-specific file for use by Pricer

Hold Harmless Payments

A3-3611.2

In FY 1992, hospitals with a hospital-specific rate for capital that is above the Federal PPS rate for the cost reporting period that ended in FY 1990 can receive the higher of: 

• The hold harmless-old capital rate, which is 100 percent of the reasonable costs of old capital for sole community hospitals, or 85 percent of the reasonable costs associated with old capital for all other hospitals, plus a payment for new capital

• The hold harmless - 100 percent Federal rate.

The A/B MAC (A) adjusts the hospital-specific rate in the cost report for the period ending in FY 1990 for case mix. It updates the rate to FY 1992 levels using the projected increase in national average capital costs per discharge to initially determine whether a hospital should be paid under the hold harmless or the fully prospective methodology. The type of methodology is entered in the provider-specific file.

Hospitals paid under the fully prospective methodology may change to the hold harmless methodology if justified by the addition of obligated capital and other changes in remaining old capital costs subsequent to the base period. This option is available through the later of a hospital's cost reporting period beginning in FY 94 or after obligated capital has been put in use. Hospitals must request an extension from the A/B MAC (A) by the later of January 1, 1993, or within 180 days of the event causing the delay, if they will be unable to put an asset in use for inpatient care by October 1, 1996. The new hospital-specific rate reflects the disposal of old assets and the addition of obligated capital costs, but not new capital acquisitions. If the recalculated hospital-specific rate exceeds the Federal rate, the hospital will be paid under the hold harmless methodology. The payment methodology in effect for FY 94 (or after the obligated capital has been put in use, if later) determines the payment methodology applicable for the remainder of the transition period under either transition payment methodology.

The A/B MAC (A) does not hold harmless a hospital for increased costs resulting from a lease arrangement entered into after December 31, 1990.

If a hospital has such low Medicare utilization in its original capital base period that it is not required to file a cost report, its hospital-specific rate will be based on its old capital costs per discharge in the first 12-month cost reporting period for which a cost report is filed.

The A/B MAC (A) converts a reasonable cost/hold harmless hospital to the 100 percent Federal payment rate when:

• Advantageous due to reductions in depreciation and/or the allowable percentage of old capital; 

• A hospital elects to be paid at 100 percent of the Federal rate; or 

• A hospital does not maintain adequate records to identify its old capital related costs. 

The A/B MAC (A) enters the payment methodology change in the provider-specific file. 

An adjustment is also provided to the Federal rate for indirect costs of medical education of interns and residents. The A/B MAC (A) calculates the adjustment by dividing the hospital's full-time equivalent total of interns and residents by the hospital's total patient days (line 8, column 6 of worksheet S3 of the CMS Form 2552-89, minus the total of the lines 1B, 1C, 1D, and 7, divided by the number of days in the cost reporting period). It reviews the hospital's records and makes any needed changes in the count at the end of the cost reporting period. It enters the indirect medical education adjustment ratio in positions 184-188 of the provider-specific file for use by Pricer

Disproportionate Share Hospital (DSH) Policy Changes

Observation Days 

For cost reporting periods beginning on or after October 1, 2009, observation days for patients later admitted as an inpatient will no longer be included in the Medicare disproportionate patient percentage (DPP). In addition, observation bed days for patients later admitted as an inpatient will no longer be counted towards a hospital’s available bed day count for DSH and IME. Between October 1, 2003, and October 1, 2009, hospitals had reported on their cost report the Medicaid observation patient days for admitted patients and total observation patient days for admitted patients for inclusion in the Medicaid fraction of the Medicare DPP, and for the determination of the available bed day count for DSH and IME. However, effective for cost reporting periods beginning on or after October 1, 2009, observation patient  days are no longer included in the DPP, and observation bed days will no longer be counted towards the available bed day count for DSH or IME.

Labor and Delivery Patient Days 

For cost reporting periods beginning on or after October 1, 2009, we will include in the Medicare disproportionate patient percentage (DPP) patient days associated with maternity patients who were admitted as inpatients and were receiving ancillary labor and delivery services at the time the inpatient routine census is taken, regardless of whether the patient occupied a routine bed prior to occupying an ancillary labor and delivery bed and regardless of whether the patient occupies a “maternity suite” in which labor, delivery, recovery and postpartum care all take place in the same room. Prior to October 1, 2009, patient days associated with beds used for ancillary labor and deliver were not counted in the DPP. However, for cost reporting periods beginning on or after October 1, 2009, but before cost reporting periods beginning on or after October 1, 2012, if a patient, admitted to the hospital as an inpatient, occupies an ancillary bed for labor and delivery, the patient days associated with the ancillary labor/delivery services will be counted in the DPP. For cost reporting periods beginning on or after October 1, 2009 but before cost reporting periods beginning on or after October 1, 2012, this policy applies only to counting patient days, and does not change the policy of determining the number of available beds in 42 CFR 412.106(a). Beds associated with ancillary labor/delivery services are not included in the available bed day count.

Reporting Inpatient Days in the Numerator of the Medicaid Fraction 

Hospitals can report days in the numerator of the Medicaid fraction by one of three methodologies. For cost reporting periods beginning on or after October 1, 2009, hospitals can report Medicaid-eligible days based on date of discharge, date of admission, or dates of service. A hospital is required to notify CMS (through the fiscal intermediary or MAC) in writing if the hospital chooses to change its methodology of counting days in the numerator of the Medicaid fraction. The written notification should be submitted at least 30 days prior to the beginning of the cost reporting period to which the change would apply. The written notification must specify the changed methodology the hospital wishes to use and the cost reporting period for which the methodology would apply. The change in methodology would be effective on the first day of the specified cost reporting period for the entire cost reporting period. The change would be effective for all future cost reporting periods unless the hospital submits a subsequent written notification to change its methodology.

Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost Reporting Periods beginning on or after October 1, 2012 (Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12)

Labor and Delivery Bed Days 

Effective for cost reporting periods beginning on or after October 1, 2012, we will include bed days associated with ancillary labor/delivery services to determine the number of beds in 42CFR412.105(b), which is cross-referenced in 42 CFR412.106(a)(1)(i) for the purposes of determining the DSH payment adjustment. Bed days associated with ancillary labor/delivery services will be included to determine the number of beds for DSH and IME. For cost reporting periods beginning before October 1, 2012, bed days associated with ancillary labor and delivery services were not counted in the available bed day count for DSH and IME.

MTUS indicator of CMS 1500

Methodology for Coding Number of Services, MTUS Count and MTUS Indicator Fields

The following instructions should be used as a guide for coding the number of services, MTUS Count and MTUS Indicator fields on the Part B Physician/Supplier Claim. These fields are documented in the CMS National Claims History Data Dictionary as CWFB_SRVC_CNT, CWFB_MTUS_CNT, and CWFB_MTUS_IND_CD, respectively.

Services not falling into examples B, C, E, or F should be coded as shown in example D (services/pricing units).

A. No Allowed Services – (CWFB_MTUS_IND_CD = 0)

For claims reporting no allowed services, the following example should be used to code the line item:
A total of 2 visits was reported for HCPCS code 99211: Office or other outpatient visit for the management of an established patient. Both services were denied.
Number of services: 2 (furnished)
                              MTUS (services): 0 (allowed)
                              MTUS indicator: 0

B. Ambulance Miles - (CWFB_MTUS_IND_CD = 1)

Signature of provider - Box 31 CMS 1500

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

How to Filing Form CMS-1500 - Tips to submit claim

Filing Form CMS-1500

Medicare Part B physicians may use the red-printed Form CMS-1500 to file various health insurance claims to private insurers and government programs. However, payment for paper claims takes substantially longer than payment for electronically submitted claims. Generally, electronic claims can be paid 14 days after submission, as opposed to paper claims that process in about four weeks. 

How Paper Claim Submission 

Works When filing paper claims, physicians must type or machine-print all mandated claim fields on the red-printed Form CMS-1500 and mail it to the local carrier. Some carriers may be able to accept a black and white copy of Form CMS-1500. Other carriers may not accept black and white copies of the form if they are using Optical Character Recognition (OCR) equipment to process the form.

Optical Character Recognition 

Carriers that process claims with OCR, use an automated scanning process similar to scanners that read price labels in grocery stores. OCR claims processing is faster and more accurate than systems requiring manual input. However, to work properly, OCR must accurately read and interpret the characters entered in each field. It reads only typed or machine-printed data. Only an original, red and white Form CMS-1500 may be submitted. Black and white photocopies cannot be machine read and will be returned. 

After claims information is scanned, it is transmitted to the claims processing system, where it is validated. 

To ensure accurate, quick claim processing, the following guidelines must be followed: 

*Do not staple, clip, or tape anything to Form CMS-1500

*Place all necessary documentation in the envelope with Form CMS-1500 

* Put the patient ’ s name and Medicare number on each piece of documentation submitted 

* Use dark ink 

* Use only upper-case (CAPITAL) letters 

* Use 10 or 12 pitch (pica) characters and standard dot matrix fonts 

* Do not mix character fonts on the same form 

* Do not use italics or script 

* Avoid using old or worn print bands or ribbons

* Do not use dollar signs, decimals, or punctuation 

* Enter all information on the same horizontal plane within the designated field 

* Do not print, hand-write, or stamp any extraneous data on the form 

* Use only lift-off correction tape to make corrections 

* Ensure data is in the appropriate field and does not overlap into other fields 

* Remove pin-fed edges at side perforations 

* Use only an original red-ink-on-white-paper Form CMS-1500

Type of Service Indicators - CMS BOX 24

Type of Service Indicators - CMS BOX 24

The place of service or diagnosis may be considered when determining the appropriate TOS. The descriptors for each of the TOS codes listed in the following table are:

Type of Service Indicators

Description of Field 17 of CMS 1500 claim

 Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;

CMS 1500 Box 13 - patient Singnature on file

The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

KIDNEY DISEASE PROGRAM BILLING - how to fill HCFA

CMS-1500  KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

CMS 1500 BLOCK TO BLOCK BILLING INSTRUCTIONS

Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: (http://www.cms.hhs.gov/providers/edi/cms1500.pdf)

For Kidney Disease claims processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

The following fields MUST be completed on the CMS-1500:


Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Kidney Disease Program card.

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

CLAIM SUBMISSION CHECKLIST

Prior to submitting your claims to the Kidney Disease Program, use the following checklist:
�� Is your copy legible? Did you type or print your form? Although not required, typing the form will speed up the process.
�� Did you follow the Billing Instructions?
�� Do you have the correct address for submitting your claims? Correct address for submission is listed on page 1 of these billing instructions.


CLAIM TROUBLESHOOTING

This section provides information about the most common billing errors encountered when
providers submit claims to the Kidney Disease Program. Preventing errors on the claim is
the most efficient way to ensure that your claims are paid in a timely manner.


Claims commonly reject for the following reasons:1. The appropriate provider and/or recipient identification is missing or inaccurate.

�� Verify that the 6 digit Kidney Disease Program Patient Identification number is entered in Block 10D. This ID number must be entered or claim will reject for invalid KDP recipient.

�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

completing CMS 1500 instruction - Field 1 - 13

Tips for Completing the CMS-1500 Claim Form

Member Information (Fields 1-13)

Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

Field Number : 1a
Field Description : Insured's ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.

Field Number : 2
Field Description : Patient's name
Data Type : Required
Instructions :  Enter the patient's last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.

Field Number :  3
Field Description : Patient's birth date and gender
Data Type : Required
Instructions : Enter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.



Field Number : 4

Medical billing CMS 1500 - hint & tips to complete claim

Required Fields – Professional Claims - CMS1500 (08-05)

CMS1500 FL #            Description of Information Required

1a Patient’s ID Number
2 Patient’s Name, as it appears on identification card
3 Patient’s Date of Birth (mm/dd/ccyy) and Sex
4 Subscriber’s Name—if same as patient, enter SAME.
5 Patient’s address—if different from subscriber’s, complete item 7
9-9d Other insurance information—if applicable. DOB must be in mm/dd/ccyy format.
10a-c If services are related to patient’s employment, auto accident or other accident, please complete. Otherwise leave blank.
11a-c Subscriber’s Insurance Group Number, Subscriber’s DOB (mm/dd/ccyy), Subscriber’s Sex
11d “Yes/No”—If “yes”, complete Item 9.
14 Date of onset of current illness or injury. (Use LMP for pregnancy)
17 Name of referring physician—required for lab and radiology claims only
17a Shaded area—Legacy qualifier / legacy number of referring physician (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
17b NPI of referring physician

Tips for Completing the CMS-1500 Claim Form - Field 14 -33

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.

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

INTRODUCTION

These billing instructions have been prepared to provide proper procedures and instructions for
the Kidney Disease Program providers who use the CMS-1500 (08-05) form.

BILLING INFORMATION

Providers must bill on the CMS-1500 claim form. Claims can be submitted in any quantity and
at any time within the filing limitation.

Filing Statutes: Claims must be received within 6 months of the date of service. The following
statutes are in addition to the initial claim submission.

• 3 months from the date of any intermediary payment, i.e., Medicare, other third party insurance (Must include copy of EOB.)

PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS

Billing a CMS-1500 with a Medicare EOMB:

On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines.
• When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB.
o Dates of service must match
o Procedure codes must match
o Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB.

• Each CMS-1500 claim must be totaled with accompanying EOB attached.

• When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. In order for KDP to pay for co-insurance and deductibles, the CMS-1500 and the Medicare EOMB must be submitted.

Claims should be sent to the original claims address:
Kidney Disease Program
201 W. Preston Street, SS3
Baltimore, MD 21203

The Program will not accept computer-generated reports from the provider’s office as proof of timely filing. The only documentation that will be accepted is a remittance advice, Medicare/Third-party EOB, and/or a returned date stamped claim from the Program.

All claims should be mailed to the following address:

Department of Health and Mental Hygiene
Kidney Disease Program
201 W. Preston Street, Room SS3
Baltimore, MD 21201 

CMS 1500 Fiels 1 - 10 - Instruction to file the claim

Top section of the CMS 1500 form

Box 1a - Required

Recipient ID Number
�� Enter the client’s eight-character prime identification number.
�� Enter the number exactly as it appears on the Medical Care Identification.

Box 17 - 23 - How to file the claim - CMS 1500

Middle section of CMS 1500 form

Box 17a - Optional

Referring Provider Number

�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).

SAMPLE CMS - 1500 form

Click the image for see full size sample CMS 1500 claim form.

CMS 1500 - points to remember

Claim form billing instructions - CMS 1500

Overview


This step-by-step presentation is intended to provide information to assist those who bill the Division of Medical Assistance Programs (DMAP) for Medicaid services complete the 08/05 CMS 1500 billing form correctly the first time. If applicable, this presentation is to be used in conjunction with General Rules, provider guidelines and supplemental information.