assignment of benefits box on cms 1500

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Medicare Assignment: Everything You Need to Know

Medicare assignment.

Providers Accepting Assignment
Providers Who Do Not
Billing Options
Assignment of Benefits
How to Choose

Frequently Asked Questions

Medicare assignment is an agreement between Medicare and medical providers (doctors, hospitals, medical equipment suppliers, etc.) in which the provider agrees to accept Medicare’s fee schedule as payment in full when Medicare patients are treated.

This article will explain how Medicare assignment works, and what you need to know in order to ensure that you won’t receive unexpected bills.

fizkes / Getty Images

There are 35 million Americans who have Original Medicare. Medicare is a federal program and most medical providers throughout the country accept assignment with Medicare. As a result, these enrollees have a lot more options for medical providers than most of the rest of the population.

They can see any provider who accepts assignment, anywhere in the country. They can be assured that they will only have to pay their expected Medicare cost-sharing (deductible and coinsurance, some or all of which may be paid by a Medigap plan , Medicaid, or supplemental coverage provided by an employer or former employer).

It’s important to note here that the rules are different for the 29 million Americans who have Medicare Advantage plans. These beneficiaries cannot simply use any medical provider who accepts Medicare assignment.

Instead, each Medicare Advantage plan has its own network of providers —much like the health insurance plans that many Americans are accustomed to obtaining from employers or purchasing in the exchange/marketplace .

A provider who accepts assignment with Medicare may or may not be in-network with some or all of the Medicare Advantage plans that offer coverage in a given area. Some Medicare Advantage plans— health maintenance organizations (HMOs) , in particular—will only cover an enrollee’s claims if they use providers who are in the plan's network.

Other Medicare Advantage plans— preferred provider organizations (PPOs) , in particular—will cover out-of-network care but the enrollee will pay more than they would have paid had they seen an in-network provider.

Original Medicare

The bottom line is that Medicare assignment only determines provider accessibility and costs for people who have Original Medicare. People with Medicare Advantage need to understand their own plan’s provider network and coverage rules.

When discussing Medicare assignment and access to providers in this article, keep in mind that it is referring to people who have Original Medicare.

How to Make Sure Your Provider Accepts Assignment

Most doctors, hospitals, and other medical providers in the United States do accept Medicare assignment.

Provider Participation Stats

According to the Centers for Medicare and Medicaid Services, 98% of providers participate in Medicare, which means they accept assignment.

You can ask the provider directly about their participation with Medicare. But Medicare also has a tool that you can use to find participating doctors, hospitals, home health care services, and other providers.

There’s a filter on that tool labeled “Medicare-approved payment.” If you turn on that filter, you will only see providers who accept Medicare assignment. Under each provider’s information, it will say “Charges the Medicare-approved amount (so you pay less out-of-pocket).”

What If Your Provider Doesn’t Accept Assignment?

If your medical provider or equipment supplier doesn’t accept assignment, it means they haven’t agreed to accept Medicare’s approved amounts as payment in full for all of the services.

These providers can still choose to accept assignment on a case-by-case basis. But because they haven’t agreed to accept Medicare assignment for all services, they are considered nonparticipating providers.

Note that "nonparticipating" does not mean that a provider has opted out of Medicare altogether. Medicare will still pay claims for services received from a nonparticipating provider (i.e., one who does not accept Medicare assignment), whereas Medicare does not cover any of the cost of services obtained from a provider who has officially opted out of Medicare.

If a Medicare beneficiary uses a provider who has opted out of Medicare, that person will pay the provider directly and Medicare will not be involved in any way.

Physicians Who Have Opted Out

Only about 1% of all non-pediatric physicians have opted out of Medicare.

For providers who have not opted out of Medicare but who also don’t accept assignment, Medicare will still pay nearly as much as it would have paid if you had used a provider who accepts assignment. Here’s how it works:

Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment.
The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as the limiting charge . But the 15% cap does not apply to medical equipment suppliers; if they do not accept assignment with Medicare, there is no limit on how much they can charge the person receiving care. This is why it’s particularly important to make sure that the supplier accepts Medicare assignment if you need medical equipment.
The nonparticipating provider may require the person receiving care to pay the entire bill up front and seek reimbursement from Medicare (using Form CMS 1490-S ). Alternatively, they may submit a claim to Medicare on behalf of the person receiving care (using Form CMS-1500 ).
A nonparticipating provider can choose to accept assignment on a case-by-case basis. They can indicate this on Form CMS-1500 in box 27. The vast majority of nonparticipating providers who bill Medicare choose to accept assignment for the claim being billed.
Nonparticipating providers do not have to bill your Medigap plan on your behalf.

Billing Options for Providers Who Accept Medicare

When a medical provider accepts assignment with Medicare, part of the agreement is that they will submit bills to Medicare on behalf of the person receiving care. So if you only see providers who accept assignment, you will never need to submit your own bills to Medicare for reimbursement.

If you have a Medigap plan that supplements your Original Medicare coverage, you should present the Medigap coverage information to the provider at the time of service. Medicare will forward the claim information to your Medigap insurer, reducing administrative work on your part.

Depending on the Medigap plan you have, the services that you receive, and the amount you’ve already spent in out-of-pocket costs, the Medigap plan may pay some or all of the out-of-pocket costs that you would otherwise have after Medicare pays its share.

(Note that if you have a type of Medigap plan called Medicare SELECT, you will have to stay within the plan’s network of providers in order to receive benefits. But this is not the case with other Medigap plans.)

After the claim is processed, you’ll be able to see details in your MyMedicare.gov account . Medicare will also send you a Medicare Summary Notice. This is Medicare’s version of an explanation of benefits (EOB) , which is sent out every three months.

If you have a Medigap plan, it should also send you an EOB or something similar, explaining the claim and whether the policy paid any part of it.

What Is Medicare Assignment of Benefits?

For Medicare beneficiaries, assignment of benefits means that the person receiving care agrees to allow a nonparticipating provider to bill Medicare directly (as opposed to having the person receiving care pay the bill up front and seek reimbursement from Medicare). Assignment of benefits is authorized by the person receiving care in Box 13 of Form CMS-1500 .

If the person receiving care refuses to assign benefits, Medicare can only reimburse the person receiving care instead of paying the nonparticipating provider directly.

Things to Consider Before Choosing a Provider

If you’re enrolled in Original Medicare, you have a wide range of options in terms of the providers you can use—far more than most other Americans. In most cases, your preferred doctor and other medical providers will accept assignment with Medicare, keeping your out-of-pocket costs lower than they would otherwise be, and reducing administrative hassle.

There may be circumstances, however, when the best option is a nonparticipating provider or even a provider who has opted out of Medicare altogether. If you choose one of these options, be sure you discuss the details with the provider before proceeding with the treatment.

You’ll want to understand how much is going to be billed and whether the provider will bill Medicare on your behalf if you agree to assign benefits (note that this is not possible if the provider has opted out of Medicare).

If you have supplemental coverage, you’ll also want to check with that plan to see whether it will still pick up some of the cost and, if so, how much you should expect to pay out of your own pocket.

A medical provider who accepts Medicare assignment is considered a participating provider. These providers have agreed to accept Medicare’s fee schedule as payment in full for services they provide to Medicare beneficiaries. Most doctors, hospitals, and other medical providers do accept Medicare assignment.

Nonparticipating providers are those who have not signed an agreement with Medicare to accept Medicare’s rates as payment in full. However, they can agree to accept assignment on a case-by-case basis, as long as they haven’t opted out of Medicare altogether. If they do not accept assignment, they can bill the patient up to 15% more than the Medicare-approved rate.

Providers who opt out of Medicare cannot bill Medicare and Medicare will not pay them or reimburse beneficiaries for their services. But there is no limit on how much they can bill for their services.

A Word From Verywell

It’s in your best interest to choose a provider who accepts Medicare assignment. This will keep your costs as low as possible, streamline the billing and claims process, and ensure that your Medigap plan picks up its share of the costs.

If you feel like you need help navigating the provider options or seeking care from a provider who doesn’t accept assignment, the Medicare State Health Insurance Assistance Program (SHIP) in your state may be able to help.

A doctor who does not accept Medicare assignment has not agreed to accept Medicare’s fee schedule as payment in full for their services. These doctors are considered nonparticipating with Medicare and can bill Medicare beneficiaries up to 15% more than the Medicare-approved amount.

They also have the option to accept assignment (i.e., accept Medicare’s rate as payment in full) on a case-by-case basis.

There are certain circumstances in which a provider is required by law to accept assignment. This includes situations in which the person receiving care has both Medicare and Medicaid. And it also applies to certain medical services, including lab tests, ambulance services, and drugs that are covered under Medicare Part B (as opposed to Part D).

In 2021, 98% of American physicians had participation agreements with Medicare, leaving only about 2% who did not accept assignment (either as a nonparticipating provider, or a provider who had opted out of Medicare altogether).

Accepting assignment is something that the medical provider does, whereas assignment of benefits is something that the patient (the Medicare beneficiary) does. To accept assignment means that the medical provider has agreed to accept Medicare’s approved fee as payment in full for services they provide.

Assignment of benefits means that the person receiving care agrees to allow a medical provider to bill Medicare directly, as opposed to having the person receiving care pay the provider and then seek reimbursement from Medicare.

Centers for Medicare and Medicaid Services. Medicare monthly enrollment .

Centers for Medicare and Medicaid Services. Annual Medicare participation announcement .

Centers for Medicare and Medicaid Services. Lower costs with assignment .

Centers for Medicare and Medicaid Services. Find providers who have opted out of Medicare .

Kaiser Family Foundation. How many physicians have opted-out of the Medicare program ?

Center for Medicare Advocacy. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) updates .

Centers for Medicare and Medicaid Services. Check the status of a claim .

Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 26 - completing and processing form CMS-1500 data set .

Centers for Medicare and Medicaid Services. Ambulance fee schedule .

Centers for Medicare and Medicaid Services. Prescription drugs (outpatient) .

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

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Find-A-Code Articles, Published 2014, August 1

What does accept assignment mean.

by InstaCode Institute Aug 1st, 2014 - Reviewed/Updated Mar 5th

What does it mean to accept assignment on the CMS 1500 claim form - also called the HCFA 1500 claim form.? Should I accept assignment or not? What are the guidelines for accepting assignment in box 27 of the 1500 claim?

These commonly asked questions should have a simple answer, but the number of court cases indicates that it is not as clear cut as it should be. This issue is documented in the book “Problems in Health Care Law” by Robert Desle Miller. The definition appears to be in the hands of the courts. However, we do have some helpful guidelines for you.

One major area of confusion is the relationship between box 12, box 13 and box 27. These are not interchangeable boxes and they are not necessarily related to each other.

According to the National Uniform Claim Committee (NUCC), the "Accept Assignment" box indicates that the provider agrees to accept assignment. It simply says to enter an X in the correct box. It does NOT define what accepting assignment might or might not mean.

It is important to understand that if you are a participating provider in any insurance plan or program, you must first follow the rules according to the contract that you sign. That contract supersedes any guidelines that are included here.

Medicare Instructions / Guidelines

PARTICIPATING providers MUST accept assignment according to the terms of their contract. The contract itself states:

“Meaning of Assignment - For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment , the approved charge, determined by the Medicare carrier, shall be the full charge for the service covered under Part B. The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.”

By law, the providers or types of services listed below MUST also accept assignment:

Clinical diagnostic laboratory services;
Physician services to individuals dually entitled to Medicare and Medicaid;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
Ambulatory surgical center services for covered ASC procedures;
Home dialysis supplies and equipment paid under Method II;
Ambulance services;
Drugs and biologicals; and
Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

NON-PARTICIPATING providers can choose whether to accept assignment or not, unless they or the service they are providing is on the list above.

The official Medicare instructions regarding Boxes 12 and 13 are:

“Item 12 – The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payments of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.” “Item 13 - 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.”

Regardless of the wording on these instructions stating that it authorizes payments to the physician, this is not enough to ensure that payment will come directly to you instead of the patient.To guarantee payment comes to you, you MUST accept assignment.

Under Medicare rules, PARTICIPATING providers are paid at 80% of the physician fee schedule allowed amount and NON-participating providers are paid at 80% of the allowed amount, which is 5% less than the full Allowed amount for participating providers. Only NON-participating providers may "balance bill" the patient for any amounts not paid by Medicare, however, they are subject to any state laws regarding balance billing.

TIP: If you select YES, you may or may not be subject to a lower fee schedule, but at least you know the payment is supposed to come to you.

NON-MEDICARE Instructions / Guidelines

PARTICIPATING providers MUST abide by the terms of their contract. In most cases, this includes the requirement to accept assignment on submitted claims.

NON-PARTICIPATING providers have the choice to accept or not accept assignment.

YES means that payment should go directly to you instead of the patient. Generally speaking, even if you have an assignment of benefits from the patient (see box 12 & 13), payment is ONLY guaranteed to go to you IF you accept assignment.

NO is appropriate for patients who have paid for their services in full so they may be reimbursed by their insurance. It generally means payment will go to the patient.

What Does Accept Assignment Mean?. (2014, August 1). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/what-does-accept-assignment-mean-34840.html

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CMS-1500 Claim Form Cheat Sheet

Here is a breakdown of each box on the cms-1500 and where they populate from within your unified practice account..

Jump to:

Boxes #1 through #13
Boxes #14 through #23
Box #24a-#24j
Boxes #25 through #33b

Box Number: 1 - Insurance Name Where this populates from: Billing Info > Billing Preferences > Insurance Type Description: Where the type of health insurance coverage applicable to this claim is selected. There are seven plan types to select from, by checking the appropriate box. Only one plan type is allowed to be selected.

Box Number: 1a - Insured’s ID Number Where this populates from: Patient File > Insurance tab > Card Info, ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's ID number is entered as shown on their ID card for the payer to which the claim is being submitted.

Box Number: 2 - Patient’s Name Where this populates from: Personal tab of Patient File Description: Where the patient's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 3 - Patient’s Birthdate and Sex Where this populates from: Personal tab of Patient File Description: Where the patient's 8-digit birth date is entered in the format MMDDYYYY. As well, the appropriate box should be marked indicating the sex (gender) of the patient. Only one box can be marked.

Box Number: 4 - Insured’s Name Where this populates from: Personal tab of Patient File OR if covered under someone else, Patient File > Insurance Tab > Card Info > ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 5 - Patient’s Address Where this populates from: Personal tab of Patient File Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 6 - Patients relationship to Insured Where this populates from: Insurance tab of the Patient File (If "Covered under someone else's insurance plan?" is switched to Yes OR patient can fill out during onboarding). Description: Where the patient's relationship to the insured is entered. Only one box can be marked.

Box Number: 7 - Insured Address Where this populates from: Personal tab of Patient File OR Patient File > Insurance Tab > Insured under someone else fields. Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 8 - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Reserved field. It was previously used to report Patient Status. Patient Status no longer exists, so this field has been eliminated.

Box Number: 9 - Other Insured’s Name Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: Indicates that there is a holder of another policy that may cover the patient. The insured's name is entered as Last Name, First Name, Middle Initial, separated by commas. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 9a - Other Insured's Policy or Group Number Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: The other insured's policy or group number as it appears on the insured's health care identification card for secondary insurance. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 9b - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9b is now a reserved field. It was previously used to report Other Insured's Date of Birth, Sex . Other Insured's Date of Birth, Sex no longer exists, so this field has been eliminated.

Box Number: 9c - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9c is now a reserved field. It was previously used to report Employer’s Name or School Name . Employer’s Name or School Name no longer exists, so this field has been eliminated.

Box Number: 9d - Insurance Plan Name or Program Name Where this populates from: can not be modified within Unified Practice Description: Box 9d is the name of the insurance plan or program of the other insured as indicated in Box 9. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 10 - Is Patient's Condition Related To Where this populates from: Billing Info > Billing Preferences > Is Patient's condition related to (this carries over from treatment to treatment). Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked “YES” indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10a - Employment Where this populates from: Employment (current or previous) would indicate that the condition is related to the patient’s job or workplace. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10b - Auto Accident Where this populates from: Auto accident would indicate that the condition is the result of an automobile accident. The state postal code where the accident occurred must be reported if YES is marked in 10b for “Auto Accident.” Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10c - Other Accident Where this populates from: Other accident would indicate that the condition is the result of any other type of accident. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10d - Reserved for Local Use Where this populates from: can not be modified within Unified Practice Description: Used to identify additional information about the patient’s condition or the claim. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field.

Box Number: 11 - Insured Policy Group or FECA Number Where this populates from: Billing Info > Billing Preferences > select which company is being used as Primary for this visit. Description: The insured's policy or group number as it appears on the insured's health care identification card.

Box Number: 11a - Insured Date of Birth and Sex Where this populates from: Personal tab of Patient File Description: Where the insured's 8-digit date of birth in the format MMDDYYYY is entered and a box indicating the insured's gender is marked.

Box Number: 11b - Other Claim ID (Designated by NUCC) Where this populates from: can not be modified within Unified Practice Description: The other claim ID. Claim identifiers are designated by the NUCC.

Box Number: 11c - Insurance Plan Name Or Program Name Where this populates from: Insurance tab of Patient File by selecting the Insurance Plan (goes for all types). Description: The name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.

Box Number: 11d - Is there another Health Benefit Plan Where this populates from: Billing Info > Billing Preferences > Secondary Insurance Description: If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. This specifies if there is another health benefit plan attached to this claim. Mark the appropriate box ( Yes or No ). Only one box can be marked.

Box Number: 12 - Patients or Authorized Person’s Signature Where this populates from: Billing Info > Billing Preferences > Signature Date . If switched to Yes, you can enter the date. Otherwise, this is left blank. Description: Where the signature and date indicating authorization to release any medical information needed to process and/or adjudicate the claim. This can be done by entering Signature on File , SOF or the actual signature.

Box Number: 13 - Insured’s or Authorized Person’s Signature Where this populates from: This is automatically populated by Unified Practice with Signature on File. Description: Where the signature indicating authorization of payment for medical benefits to the provider of service. This can be done by entering Signature on File , SOF or the actual signature.

Box Number: 14 - Date of Current Illness, Injury, or Pregnancy Where this populates from: Billing Info > Billing Preferences > Onset Date Description: Identifies the first date of onset of illness, the actual date of injury, or the LMP for pregnancy. Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.

Box Number: 15 - Other Date Where this populates from: Billing Info > Billing Preferences > Other Date Description: Where another date related to the patient’s condition or treatment is entered. Enter the applicable qualifier to identify which date is being reported. 454 Initial Treatment, 304 Latest Visit or Consultation, 453 Acute Manifestation of a Chronic Condition, 439 Accident, 455 Last X-ray, 471 Prescription, 090 Report Start (Assumed Care Date), 091 Report End (Relinquished Care Date), 444 First Visit or Consultation.

Box Number: 16 - Dates patient unable to work in current occupation Where this populates from: can not be modified within Unified Practice Description: Where the time span the patient is, or was, unable to work is entered if the patient is employed and is unable to work in their current occupation. A 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

Box Number: 17 - Name of Referring Provider or other Source Where this populates from: [1.] Patient File > Personal Tab > Edit > Referring Provider [2.] Billing Info > Billing Preferences > Fill in referring providers details toggle switched to Yes Description: Where the name of the referring provider, ordering provider, or supervising provider who referred, ordered or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported. DN Referring Provider, DK Ordering Provider

Box Number: 17a Where this populates from: This field can not be populated from Unified Practice

Box Number: 17b - NPI Where this populates from: Patient File > Personal Tab > Edit > Referring Provider > Add new provider > NPI Description: Where the NPI number of the referring, ordering, or supervising provider is entered. The NPI number refers to the HIPAA National Provider Identifier number.

Box Number: 18 - Hospitalization dates related to current services Where this populates from: can not be modified within Unified Practice Description: Where you would refer to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Box Number: 19 - Additional Claim Information Where this populates from: Billing Info > Billing Preferences , Additional Claim Information Description: Used to identify additional information about the patient’s condition or the claim. Please refer to the most current instructions from the public or private payer regarding the use of this field. Some payers ask for certain identifiers in this field. If identifiers are reported in this field, enter the appropriate qualifiers describing the identifier.

Box Number: 20 - Outside Lab, $ charges Where this populates from: Billing Info > Billing Preferences > Outside Lab Description: Used to indicate that services have been rendered by an independent provider.

Box Number: 21- Diagnostic or Nature of Illness or Injury (ICD Ind) Where this populates from: Billing Info > ICD codes Description: Used to identify the applicable ICD indicator to specify which version of ICD codes are being reported. 9 ICD-9 0 ICD-10 Box 21, Lines A through L, are used to indicate the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. Up to 12 ICD-9-CM or ICD-10-CM diagnosis codes can be entered.

Box Number: 22 - Resubmission Code, Original Ref No. Where this populates from: Billing Info > Billing Preferences > Resubmission code (left), Original reference number (right) Description: Used to list the original reference number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field. 6 Corrected Claim 7 Replacement of prior claim 8 Void/cancel of prior claim

Box Number: 23 - Prior Authorization number Where this populates from: Patient File > Insurance tab > Prior authorization turned on > Authorization # Description: Used to show the payer assigned number authorizing the service(s).

Box Number: 24 Description: Used to list the completed services for the claim. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each Item Number. Providers must verify requirements for this supplemental information with the payer.

Box Number: 24a - Dates of Service Where this populates from: Appointment Date Description: Indicates the actual month, day, and year the service(s) was provided.

Box Number: 24b - Place of service Where this populates from: Locations & Rooms > Edit Location > Facility Code Description: Used to identify the location where the service was rendered. Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed.

Box Number: 24c - EMG Where this populates from: can not be modified within Unified Practice Description: Identifies if the service was an emergency. Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the field. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined in 5010A1.

Box Number: 24d - Procedures, services, or supplies Where this populates from: Appointment bill, CPT codes -or- CPT Fee Schedule [on iPad] Description: Used to identify the medical services and procedures provided to the patient. Enter the CPT code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.

Box Number: 24e - Diagnostic pointer Where this populates from: Appointment bill, CPT codes, ICD pointer -or- Chief Complaint & ICD [on iPad] Description: Used to indicate the line letter from Box 21 that relates to the reason the service(s) was performed. Enter the diagnosis code reference letter (pointer) as shown in Box 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable. ICD-9-CM (or ICD-10-CM, once mandated) diagnosis codes must be entered in Box 21 only. Do not enter them in 24e.

Box Number: 24f - Charges Where this populates from: Fee Schedule (or if changed, charge in billing info screen) Description: The total billed amount for each service line. Enter the charge for each listed service, right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 24g - Days or Units Where this populates from: Appointment Billing Info Description: Used to indicate the number of days corresponding to the dates entered in 24A or units as defined in CPT coding manual(s). Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers left justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point.

Box Number: 24h - EPSDT Family Plan Where this populates from: cannot be modified within Unified Practice Description: Box 24h is used to identify certain services that may be covered under some state plans.

Box Number: 24i - ID Qualifier Where this populates from: cannot be modified within Unified Practice Description: Indicate the appropriate qualifier and identifying number in the shaded area.

Box Number: 24j - Rendering Provider ID# Where this populates from:

Description: Indicates the individual performing/rendering the service.

Box Number: 25 - Federal TAX ID number

Where this populates from: Account > My Account > Personal Tax ID > switch U se this ID as the Tax ID for my Superbills and Claim forms for billing toggle to Yes .

If Practitioner Tax ID is empty or Use this Tax ID… .. is turned off then it takes the Tax ID configured in Billing Information
If both are empty, the field remains empty

Description: Indicates the unique identifier assigned by a federal or state agency. Enter the Federal Tax ID Number (employer ID number or SSN) of the Billing Provider identified in Box 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.

Box Number: 26 - Patient Account Number Where this populates from: cannot be modified within Unified Practice Description: Indicates the identifier assigned by the provider.

Box Number: 27 - Accept Assignment? Where this populates from: Billing Info > Billing Preferences > Accept Assignment Description: Indicates that the provider agrees to accept assignment under the terms of the payer’s program. Enter an X in the correct box. Only one box can be marked. Report Accept Assignment? for all payers.

Box Number: 28 - Total Charge Where this populates from: Service balance due in Billing Info Description: Indicates the total billed amount for all services entered in Box 24f (lines 1–6). Enter total charges for the services (i.e., total of all charges in 24F). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 29 - Amount Paid Where this populates from: Billing Info > Billing Preferences > switch Amount Paid - fill-in amount paid by patient for services to Yes and fill in the amount. This will auto-fill from payment received/applied. Description: Indicates the payment received from the patient or other payers. Enter total amount the patient and/or other payers paid on the covered services only. Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 30 - Balance Due Where this populates from: Total charge minus balance due that is listed on the CMS-1500 form.

Box Number: 31 - Signature of Physician or Supplier Where this populates from: Name in My Account & the Date of Service - or - Clinic Settings then Clinic Staff and click Details to the right to the Practitioner's name.

The signature will reflect the name of the Practitioner assigned to the appointment - or - the last Practitioner to sign and lock the SOAP note.

Box Number: 32 - Service Facility Location Information Where this populates from: Clinic Settings > Locations & Rooms > Edit Location Description: Indicates the name and address of facility where services were rendered identifies the site where service(s) were provided. Enter the name, address, city, state, and ZIP code of the location where the services were rendered.

Box Number: 32a Where this populates from: Clinic Settings > Locations & Rooms > Edit Location > Service Facility NPI

If this is not entered, 32a remains empty.

Box Number: 32b Where this populates from: cannot be modified within Unified Practice Description: Indicates the non-NPI ID number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

Box Number: 33 - Billing Provider Info & Phone Number Where this populates from: Defaults from Business Information -or- If alternate pay to info is selected in My Account/Billing Information , will pull from there. Description: Box 33 is used to indicate the billing provider’s or supplier’s billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and ZIP Code Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Report a 9-digit ZIP code, including the hyphen. Do not use a hyphen or space as a separator within the telephone number.

Box Number: 33a - Billing Information > Billing NPI Where this populates from: Clinic Settings > Clinic Staff > Details -or- My Account if Use this NPI... is turned on .

If this is turned off for the practitioner account page, this populates from Clinic Settings > Billing information .
If both are empty, 33a remains empty.

Description: Indicates the HIPAA National Provider Identifier number. Enter the NPI number of the billing provider in 33a.

Where this populates from: Billing Info > Billing Preferences > G roup ID Description: Indicates the payer-assigned unique identifier of the professional.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin , and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions .
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Patient's Medicare number.

Insured's name if Medicare is not primary. Leave blank if Medicare is primary. May have "SAME" when insured is the patient.

These are situational if Medicare iss not primary. For Electronic claims “SAME” is not acceptable.

Patient's name - last name, first name, middle initial - must be as it appears on the Medicare Card.

Date of birth - 8 digits - MM DD YYYY entered into spaces and appropriate box checked for sex.

Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP codeand phone number.

Telephone number field not available in this format.

Check the appropriate box for patient's relationship to insured when item 4 is completed.

Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.

These are situational if Medicare is not primary. For Electronic claims “SAME” is not acceptable.

Leave blank.

Patient status field is not available in this format.

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

Items 10a - 10c

Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

If Medicare is primary, enter the word "NONE". If Medicare is secondary, enter the insured's policy or group number and proceed to items 11a through 11c. This field is required on a paper claim.

Policy number and or group number of the Medigap insured preceded by "MEDIGAP", "MG", or "MGAP."

Enter the insured's birth date and sex, if different from item 23.

ANSI 5010 - This segment has been deleted.

Enter employer's name, if applicable. If there is a change in the insured's status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Form version 02/12: provide this information to the right of the vertical dotted line.

This field is not available in this format.

Leave blank if item 9d is completed . Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card.

Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item 11.

Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier(ID) .

Patient’s Medicaid number - If patient is not enrolled in Medicaid, leave blank.

Not Needed - Medicaid automatically crosses over.

Leave blank - this is not required by Medicare.

The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Chapter 1, “General Billing Requirements.” If the patient is physically or mentally unable to sign, a representative specified in chapter 1, may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement.

NOTE: This can be “Signature on File” and/or a computer generated signature.

The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Note: The signature date field is not available in this format

Enter either a patient’s or authorized person’s signature and date or enter “Signature on File” (SOF).

Enter the date of the current illness, injury or pregnancy. For Chiropractic services, enter the date of the initiation of the course of treatment.

*Use if different information given at the claim level

Leave blank. Not required by Medicare.

If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.

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. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:

Qualifier Provider Role

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the dotted vertical line on item 17.

This block is not used after May 23, 2008.

This is not used after May 23, 2008.

Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.

Enter applicable dates (either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date), dosage, global surgery period, or other narrative information. All information listed in Item 19 and its electronic equivalent is situational.

Enter the acquisition price under “$ Charges” if the “Yes” box is checked. A “Yes” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “No” check indicates that no anti-markup tests are included on the claim. When Yes is annotated, Item 32a shall be completed.

When submitting a PS1 segment, the facility information must also be in either loop 2310D or 2420C.

The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)
If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Note: Up to eight diagnosis codes may be entered in priority order on electronic claims. Do not use decimal points.

ANSI 5010 - In addition: Up to 12 diagnoses may be entered.

Leave blank or enter one of the following items as applicable:

Quality Improvement Organization (QIO) prior authorization number
Seven-digit Investigational Device Exemption (IDE) number when used in a clinical trial
NPI of Home Health Agency or Hospice facility when Care Plan Oversight is billed
Ten-digit CLIA number when lab services are billed
For ambulance claims, enter the ZIP code of the point-of-pickup for the loaded ambulance trip

Enter the date of service - 6 digits (MMDDYY) or 8-digit (MMDDYYYY) date for each procedure or service.

Enter the appropriate two-digit place of service (POS) code to identify where the item is used or the service is performed.

Enter the procedure code and up to four applicable modifiers.

This is a required field. Enter the diagnosis code reference letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis.

Enter the charge for each listed service. Note: Nonparticipating providers may not exceed the limiting charge fee for each service.

Enter the number of days or units. For anesthesia, convert hours into minutes, if necessary, and enter the total minutes required for the procedure.

This field should be blank on all claims received after May 23, 2008. Exception: Providers who have terminated their Medicare provider numbers and were never assigned an NPI. The 1C qualifier must be in this field and there must be a comment in block 19 that this is a submission from a terminated provider.

This is only used when the exception is met and there are comments in the narrative field that the submission is from a terminated provider.

Enter the rendering provider’s NPI in the unshaded portion.

Enter the Federal Tax ID (Employer Identification Number or Social Security Number) of the provider and check the appropriate box.

Enter the patient's account number.

Check the appropriate box to indicate whether the provider accepts assignment of Medicare benefits.

Enter the total charges for the services.

Enter the total amount that the patient paid for covered services only.

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.

Enter the name and complete address including the ZIP code of the facility where the services were rendered. If the supplier is a certified mammography screening center, enter the six-digit FDA approved certification number.

Enter the provider’s billing name, address, ZIP code and telephone number.

Enter the NPI of the service facility. This is a conditional field. There should be nothing in this field unless there is a purchased test as listed in Item 20. The NPI of the provider from whom the test was purchased will be listed if this is the case.

Effective May 23, 2008 this field is not to be reported.

Enter the NPI of the billing provider or group.

Item 33b is not generally reported. However, for some Medicare policies you may be instructed to use this item; direction as to how to use this item will be in the instructions you received regarding the specific policy, if applicable.

Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.

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Accepting Assignment: HCFA 1500 claim form Boxes 27 and 13

As a provider, you have the option to accept or decline assignment of benefits in chirofusion..

When adding a new Payer in ChiroFusion, you have the ability to specify whether or not you are accepting assignment. By accepting assignment of benefits, the Payer will remit payment directly to you and not the patient. Conversely, if you choose to not accept assignment, the Payer will remit payment directly to the patient.

You can specify assignment for a particular Payer in ChiroFusion in Settings > Add/Edit Insurance Company > Clearinghouse Details. By default, this selection will apply to all patients associated with this Payer and place the "Signature on File" in Box 13 if necessary.

Insurance Company Settings:

Patient Specific Settings:

When 'Assignment' is checked in the global insurance settings, it will apply to all patients who are covered by that insurance policy. You have the ability to deselect this box for a specific patient if need be.

In Billing For Refiling Claims:

You can edit this directly in the HCFA Claim tab and it will update all claims pertaining to specific patients.

Strategic insights, perspectives and industry trends for healthcare executives. Brought to you by CareCloud .

Quick Billing Tip: Boxes 12 & 13 on the CMS 1500 Form

Boxes 12 & 13 on the CMS 1500 form are very important but are often overlooked. By overlooked, I mean that most medical billers don’t understand the importance of the boxes and just blindly fill them in.

It is important to understand what these fields ask for and to make sure they have been filled in appropriately because they can seriously affect claims payment if not completed properly.

Box 12 is the “release of information” box. Many billers think that if you don’t have to release any information, you can just leave this blank . Others think you just stick “signature on file” there and you’re good. Well, neither is correct.

Many carriers will not release payment if this box is empty. But just sticking “signature on file” in there is not correct either. You really need to know that the patient’s signature is on file.

The patient should have signed a release of information statement when he or she first came in. It is usually part of the initial paperwork that he or she completes. In any case, this is an important box that you need to pay attention to, so you’ll want to make sure this statement is completed by patients when they first come into your office.

Box 13 is the “authorization of payment of medical benefits to the provider of service.” If this box is completed, the patient is indicating that they want any payments for the services being billed to be sent directly to the provider. This doesn’t guarantee that the insurance carrier will send payment to the provider, but it indicates that the patient gives them permission to do so.

For example, if the provider is not in-network , the insurance carrier may send payment directly to the patient – even if this box is completed. And, if the provider is in-network but this box is not completed, it is possible that payment could go to the patient. So again, if you have the patient’s authorization for the payment to be made to the provider, you should make sure this box is completed to help ensure that you receive payment for services from the payer.

What issues have you encountered on the CMS 1500 form?

Alice Scott and Michele Redmond are medical billing experts, co-owners of Solutions Medical Billing Inc in Rome, N Y., and coauthors of 15 books on medical billing and medical credentialing. Their newest title is Advanced Medical Billing Marketing for the New Economy .

This mother-and-daughter team maintains two medical billing websites, a free newsletter, and an active forum. Alice and Michele are on the editorial staff of BC Advantage and are regular contributors to the magazine. Their books are available at www.medicalbillinglive.com .

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Professional paper claim form (CMS-1500)

The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies. Please contact your Medicaid State Agency for more details.

The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. CMS does not supply the form to providers for claim submission. In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).

The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers and DMERCs. You can find Medicare CMS-1500 completion and coding instructions, as well as the print specifications in Chapter 26 of the Medicare Claims Processing Manual (Pub.100-04).