CMS-1500 BILLING INSTRUCTIONS Providers must use the CMS-1500 form to bill the Program. The CMS-1500 are available from the Government Printing Office, the American Medical Association; major medical oriented printing firm, or contact the US Government Printing Office at 202-512-1800 to place an order. Instructions for the completion of each of the CMS-1500 are provided in this section. See Section XVI - Appendix, page 72 for a reproduction of a CMS-1500 showing the reference numbers of Blocks. Blocks that refer to third party payers must be completed only if there is a third party payer other than Medicare or Medicaid. The Medical Assistance Program is by law the of last resort”. If a recipient is covered by “payer other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim. PROPER COMPLETION OF CMS-1500 For Medical Assistance 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. Block 1 Show all type(s) of health insurance applicable to this claim by checking the appropriate box(es). Block 1a INSURED’S ID NUMBER Enter the patient’s Medicare number if applicable. – The patient’s (recipient’s) 11-digit Maryland Medical Assistance number is required in Block 9a. Situational. – Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) Enter the – patient’s (recipient’s) name as it appears on the Medical Assistance card. Block 3 PATIENT’S BIRTH DATE/SEX Enter the patient’s (recipient’s) date of birth – and sex. Optional. – INSURED’S NAME (Last Name, First Name, Middle Initial) Enter the name Block 4 – of the person in whose name the third party coverage is listed, only when applicable. Optional. – 5 PATIENT’S ADDRESS Enter the patient’s (recipient’s) complete mailing – address with zip code and telephone number. Optional. –
CMS-1500 BILLING INSTRUCTIONS Providers must use the CMS-1500 form to bill the Program. The CMS-1500 are available from the Government Printing Office, the American Medical Association; major medical oriented printing firm, or contact the US Government Printing Office at 202-512-1800 to place an order. Instructions for the completion of each of the CMS-1500 are provided in this section. See Section XVI - Appendix, page 72 for a reproduction of a CMS-1500 showing the reference numbers of Blocks. Blocks that refer to third party payers must be completed only if there is a third party payer other than Medicare or Medicaid. The Medical Assistance Program is by law the “payer of last resort”. If a recipient is covered by other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim. PROPER COMPLETION OF CMS-1500 For Medical Assistance 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. Block 1 Show all type(s) of health insurance applicable to this claim by checking the appropriate box(es). Block 1a INSURED’S ID NUMBER – Enter the patient’s Medicare number if applicable. The patient’s (recipient’s) 11-digit Maryland Medical Assistance number is required in Block 9a. – Situational. Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Medical Assistance card. Block 3 PATIENT’S BIRTH DATE/SEX – Enter the patient’s (recipient’s) date of birth and sex. – Optional. Block 4 INSURED’S NAME (Last Name, First Name, Middle Initial) – Enter the name of the person in whose name the third party coverage is listed, only when applicable. – Optional. 5 PATIENT’S ADDRESS – Enter the patient’s (recipient’s) complete mailing address with zip code and telephone number. – Optional.
CMS1500%20Billing%20Instructions.docx