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. EPSDT FAMILY PLAN No entry required. – – Block 24i. Enter the ID Qualifier ID. QUAL. 1D (Medicaid Provider Number) – – Block 24j. (gray shaded area) RENDERING PROVIDER ID # Enter the 9-digit MA – provider number of the practitioner rendering the service. In some instances, the rendering number may be the same as the payee provider number in Block #33. Enter the rendering provider’s NPI in the unshaded area. Block 25 FEDERAL TAX ID NUMBER – 26 PATIENT’S ACCOUNT NUMBER An alphabetic, alpha-numeric, or – – numeric patient account identifier (up to 13 characters) used by the provider’s office can be entered. If recipient’s MA number is incorrect, this number will be recorded on the Remittance Advice Block 27 ACCEPT ASSIGNMENT? For payment of Medicare coinsurance and/or – – deductibles, this Block must be checked Providers agree to accept Medicare and/or “Yes”. Medicaid assignment as a condition of participation. Note: Regulations that providers shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any participant for covered services. Block 28 TOTAL CHARGE Enter the sum of the charges shown on all lines of – – Block 24f. Block 29 AMOUNT PAID Enter the amount of any collections received from any third – – party payer, EXCEPT Medicare. If the recipient has third party insurance and the claim has been rejected, the appropriate rejection code shall be placed in Block # 11. Block 30 No entry required. RESERVED FOR NUCC USE – – Block 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREE – Please write on File” and include the date of OR CREDENTIALS – “Signature submission. Note: The date of submission must be in Block 31 in order for the claim to be reimbursed. Block 32 FACILITY LOCATION INFORMATION Complete only if –SERVICE – billing for medical laboratory services referred to another laboratory or the facility where trauma services were rendered. Enter the name and address of facility.
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. – EPSDT FAMILY PLAN – No entry required. Block 24i. – ID. QUAL. – Enter the ID Qualifier 1D (Medicaid Provider Number) Block 24j. (gray shaded area) RENDERING PROVIDER ID # – Enter the 9-digit MA provider number of the practitioner rendering the service. In some instances, the rendering number may be the same as the payee provider number in Block #33. Enter the rendering provider’s NPI in the unshaded area. Block 25 – FEDERAL TAX ID NUMBER 26 – PATIENT’S ACCOUNT NUMBER – An alphabetic, alpha-numeric, or numeric patient account identifier (up to 13 characters) used by the provider’s office can be entered. If recipient’s MA number is incorrect, this number will be recorded on the Remittance Advice Block 27 – ACCEPT ASSIGNMENT? – For payment of Medicare coinsurance and/or deductibles, this Block must be checked “Yes”. Providers agree to accept Medicare and/or Medicaid assignment as a condition of participation. Note: Regulations that providers shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any participant for covered services. Block 28 – TOTAL CHARGE – Enter the sum of the charges shown on all lines of Block 24f. Block 29 – AMOUNT PAID – Enter the amount of any collections received from any third party payer, EXCEPT Medicare. If the recipient has third party insurance and the claim has been rejected, the appropriate rejection code shall be placed in Block # 11. Block 30 – RESERVED FOR NUCC USE – No entry required. Block 31 – SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREE OR CREDENTIALS – Please write “Signature on File” and include the date of submission. Note: The date of submission must be in Block 31 in order for the claim to be reimbursed. Block 32 –SERVICE FACILITY LOCATION INFORMATION – Complete only if billing for medical laboratory services referred to another laboratory or the facility where trauma services were rendered. Enter the name and address of facility.
Section_6_2017.docx