Block 24g. Days or Units of Service Enter the total number of units or service for each – – procedure. Multiple, identical services rendered on different days should be billed on separate lines. Block 24h. 25 No entry required. – – Block 26 No entry required. – Block 27 No entry required. – Enter the sum of the charges shown on all lines of Block 24f. Block 28 Total Charge – – Block 29 entry required. –No Block 30 No entry required. – Block 31 No entry required. – Block 32 32b No entry required. – – Block 33 Billing Provider Info & Ph# Enter the name, complete street address, city, – – state, and zip code of the provider. This should be address to which claims may be returned. The nine (9) digit Maryland Medical Assistance provider number to which payment is to be made must be entered in the lower right hand section of this block. Errors in this area are likely to result in denied or misdirected payment. Enter the NPI number of the billing provider in Block # 33. Errors or Block 33a NPI – – omissions of this number will result in non-payment of claims. Block 33b (gray shaded area) Enter the ID Qualifier 1D (Medicaid Provider Number) – followed by the shaded area) 9-digit MA provider number of the provider in Block #33. Errors or omissions of this number will result in non-payment of claims. NOTE: It is the responsibility to promptly report all changes of name, pay to address, provider’s correspondence address, practice locations, tax identification number, or certification to the Provider Enrollment Unit at 410-767-5340. Completed CMS are to be mailed to the following address: 1500’s State Of Maryland Department Of Health & Mental Hygiene Medical Care Operations Administration P.O. Box 1935 Baltimore, MD 21203-1935
Block 24g. – Days or Units of Service – Enter the total number of units or service for each procedure. Multiple, identical services rendered on different days should be billed on separate lines. Block 24h. – 25 – No entry required. Block 26 – No entry required. Block 27 – No entry required. Block 28 – Total Charge – Enter the sum of the charges shown on all lines of Block 24f. Block 29 –No entry required. Block 30 – No entry required. Block 31 – No entry required. Block 32 – 32b – No entry required. Block 33 – Billing Provider Info & Ph# – Enter the name, complete street address, city, state, and zip code of the provider. This should be address to which claims may be returned. The nine (9) digit Maryland Medical Assistance provider number to which payment is to be made must be entered in the lower right hand section of this block. Errors in this area are likely to result in denied or misdirected payment. Block 33a – NPI – Enter the NPI number of the billing provider in Block # 33. Errors or omissions of this number will result in non-payment of claims. Block 33b (gray shaded area) – Enter the ID Qualifier 1D (Medicaid Provider Number) followed by the shaded area) 9-digit MA provider number of the provider in Block #33. Errors or omissions of this number will result in non-payment of claims. NOTE: It is the provider’s responsibility to promptly report all changes of name, pay to address, correspondence address, practice locations, tax identification number, or certification to the Provider Enrollment Unit at 410-767-5340. Completed CMS 1500’s are to be mailed to the following address: State Of Maryland Department Of Health & Mental Hygiene Medical Care Operations Administration P.O. Box 1935 Baltimore, MD 21203-1935