Tips For Completing The CMS-1500 Version 02/12 Claim Form

gnosis. Enter only one reference number per line. Do not enter thediagnosis code. (Electronic claims will allow up to four referencenumbers per line.)24fChargesRequiredEnter the provider’s billed charges for each service.24gDays or unitsRequiredEnter the appropriate number of units or days that correspond to the“From” and “To” dates indicated in Field 24a.24hEPSDT family planSituationalIf service was rendered as part of or in response to an EPSDT panel,mark an "X" in this block.If the provider does not have an NPI, enter the appropriate qualifier andidentifying number in the shaded area. Providers who do not have anNPI must report non-NPI identifiers on their claim forms. The qualifiersindicate the non-NPI number being reported.The NUCC defines the following qualifiers used in 5010A1:0B State License Number24iID Qual.Situational1G Provider UPIN NumberG2 Provider Commercial NumberLU Location NumberZZ Provider Taxonomy (The qualifier in the 5010A1 for ProviderTaxonomy is PXC, but ZZ will remain the qualifier for the 1500 ClaimForm. Note: This identifier is not included in this data element in5010A1.)24jRendering Provider ID#SituationalEnter the non-NPI ID number in the shaded area of the field. Enter theNPI number in the unshaded area of the field. Report the IdentificationNumber in Fields 24i and 24j only when different from data recorded infields 33a and 33b.RequiredEnter the nine-digit Employee Identification Number (EIN) or SocialSecurity Number under which payment for services is to be made forreporting earnings to the IRS. Enter an "X" in the appropriate box thatidentifies the type of ID number used for services rendered. Do notenter hyphens with numbers. Enter numbers left justified in the field.Federal Tax IDnumber and type:25Social SecurityNumberEmployer IdentificationNumber26Member's accountnumberOptionalEnter the unique number assigned by the provider for the member. Ifentered, the member account number will be returned to the provideron the Provider Summary Voucher.27Accept assignment?RequiredEnter an "X" in the appropriate box to indicate whether you will acceptassignment.6 Tips for Completing the CMS-1500 Version 02/12 Claim Form

otal chargeRequiredEnter the total charge for this claim. This is the total of all charges foreach service noted in Field 24f.29Amount paidSituationalEnter the total amount paid by the patient for services billed on thisclaim.30Reserved for NUCCUseN/A31Signature of physicianor supplier includingdegrees or credentialsRequired32Name and address offacility where serviceswere renderedRequired32aa. NPI#SituationalSignature of physician or supplier including degree(s) or credentialsand date of signature.NOTE: The person rendering care must sign and indicate licensurelevel.Enter name and address where services are rendered. This must be astreet address not a P.O. Box.Required if name and address of facility where services were rendered(field 32) is populated.Enter the NPI of the service facility.32bb. Other ID#Not RequiredNot Applicable. When present, a qualifier is required33Physician’s/supplier'sbilling: name, address,zip code and phonenumberRequiredEnter the appropriate billing information.33aNPI#RequiredEnter the NPI of the billing provider or group.33bOther ID#Not RequiredIf populated, a qualifier is required.7 Tips for Completing the CMS-1500 Version 02/12 Claim Form

Place of Service Codes (Field 24b)Be sure to complete field X with the accurate place of service code as described below.Note: Not all Place of Service codes are used by Beacon Health OptionsPlaceofServiceCode(s)Place of ServiceNamePlace of Service Description01NotCovered byBeaconPharmacyA facility or location where drugs and other medically related fields and services aresold, dispensed, or otherwise provided directly to members.02TelehealthThe location where health services and health related services are provided orreceived, through telecommunication technology.03SchoolA facility whose primary purpose is education.04Homeless ShelterA facility or location whose primary purpose is to provide temporary housing tohomeless individuals (e.g., emergency shelters, individual, or family shelters).05060708Indian Health ServiceFree-standing FacilityIndian Health ServiceProvider-based FacilityTribal 638Free-standing FacilityTribal 638Provider-based FacilityA facility or location, owned and operated by the Indian Health Service, whichprovides diagnostic, therapeutic (surgical and non-surgical), and rehabilitationservices to American Indians and Alaska Natives who do not require hospitalization.A facility or location, owned and operated by the Indian Health Service, whichprovides diagnostic, therapeutic (surgical and non-surgical), and rehabilitationservices rendered by, or under the supervision of, physicians to American Indians andAlaska Natives admitted as inpatients or outpatients.A facility or location owned and operated by a federally recognized American Indian orAlaska Native tribe or tribal organization under a 638 agreement, which providesdiagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribalmembers who do not require hospitalization.A facility or location owned and operated by a federally recognized American Indian orAlaska Native tribe or tribal organization under a 638 agreement, which providesdiagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribalmembers admitted as inpatients or outpatients.09Prison–CorrectionalFacilityA prison, jail, reformatory, work farm, detention center, or any other similar facilitymaintained by either Federal, State, or local authorities for the purpose of confinementor rehabilitation of adult or juvenile criminal offenders.10UnassignedN/A8 Tips for Completing the CMS-1500 Version 02/12 Claim Form

PlaceofServiceCode(s)Place of ServiceNamePlace of Service Description11OfficeLocation, other than a hospital, skilled nursing facility (SNF), military treatment facility,community health center, State or local public health clinic, or intermediate care facility(ICF), where the health professional routinely provides health examinations,diagnosis, and treatment of illness or injury on an ambulatory basis.12HomeLocation, other than a hospital or other facility, where the patient receives care in aprivate residence.13Assisted Living FacilityCongregate residential facility with self-contained living units providing assessment ofeach resident’s needs and on-site support 24 hours a day, seven days a week, withthe capacity to deliver or arrange for services including some health care and otherservices.14Group HomeA residence, with shared living areas, where clients receive supervision and otherservices such as social and/or behavioral services, custodial service, and minimalservices (e.g., medication administration).15Mobile UnitA facility/unit that moves from place-to-place equipped to provide preventive,screening, diagnostic, and/or treatment services.16Temporary LodgingA short term accommodation such as a hotel, camp ground, hostel, cruise ship, orresort where the member receives care, and which is not identified by any other POScode.Walk in Retail HealthClinicA walk-in health clinic, other than an office, urgent care facility, pharmacy orindependent clinic and not described by any other Place of Service code, that islocated within a retail operation and provides, on an ambulatory basis, preventive andprimary care services. (Effective May 1, 2010)17NotCovered byBeacon18NotCovered byBeacon1920Place of EmploymentWorksiteOutpatient Hospital-OffcampusUrgent Care FacilityA location, not described by any other POS code, owned or operated by a public orprivate entity where the patient is employed, and where a health professional provideson-going or episodic occupational medical, therapeutic, or rehabilitative services to theindividual. (This code is available for use effective January 1, 2013 but no later thanMay 1, 2013)A portion of a hospital off-campus which provides diagnostic, therapeutic (bothsurgical and non-surgical), and rehabilitation services to sick or injured persons whodo not require hospitalization or institutionalization.Location, distinct from a hospital emergency room, an office, or a clinic, whosepurpose is to diagnose and treat illness or injury for unscheduled, ambulatorymembers seeking immediate medical attention. (Effective January 1, 2003)9 Tips for Completing the CMS-1500 Version 02/12 Claim Form

PlaceofServiceCode(s)Place of ServiceNamePlace of Service Description21Inpatient HospitalA facility, other than a psychiatric facility, which primarily provides diagnostic,therapeutic (both surgical and non-surgical), and rehabilitation services by, or under,the supervision of physicians to members admitted for a variety of medical conditions.22On Campus-OutpatientHospitalA portion of a hospital on campus which provides diagnostic, therapeutic (bothsurgical and non-surgical), and rehabilitation services to sick or injured persons whodo not require hospitalization or institutionalization.23Emergency Room–HospitalA portion of a hospital where emergency diagnosis and treatment of illness or injury isprovided.Ambulatory SurgicalCenterA freestanding facility, other than a physician's office, where surgical and diagnosticservices are provided on an ambulatory basis.Birthing CenterA facility, other than a hospital's maternity facilities or a physician's office, whichprovides a setting for labor, delivery, and immediate post-partum care as well asimmediate care of newborn infants.NotCovered byBeaconMilitary Treatment FacilityA medical facility operated by one or more of the Uniformed Services. MilitaryTreatment Facility (MTF) also refers to certain former U.S. Public Health Service(USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).27-30UnassignedN/A31Skilled Nursing FacilityA facility which primarily provides inpatient skilled nursing care and related services tomembers who require medical, nursing, or rehabilitative services but does not providethe level of care or treatment available in a hospital.32Nursing FacilityA facility which primarily provides to residents skilled nursing care and related servicesfor the rehabilitation of injured, disabled, or sick persons, or, on a regular basis,health-related care services above the level of custodial care to other than mentallyretarded individuals.33Custodial Care FacilityA facility which provides room, board, and other personal assistance services,generally on a long-term basis, and which does not include a medical component.34HospiceA facility, other than a member’s home, in which palliative and supportive care forterminally ill patients and their families are provided.2425NotCovered byBeacon2610 Tips for Completing the CMS-1500 Version 02/12 Claim Form

PlaceofServiceCode(s)Place of ServiceNamePlace of Service Description35-40UnassignedN/A41Ambulance–LandA land vehicle specifically designed, equipped, and staffed for lifesaving andtransporting the sick or injured.42Ambulance–Air or WaterAn air or water vehicle specifically designed, equipped, and staffed for lifesaving andtransporting the sick or injured.43-48UnassignedN/A49Independent ClinicA location, not part of a hospital and not described by any other POS code, that isorganized and operated to provide preventive, diagnostic, therapeutic, rehabilitative,or palliative services to outpatients only. (Effective October 1, 2003)50Federally QualifiedHealth CenterA facility located in a medically underserved area that provides Medicare beneficiariespreventive primary medical care under the general direction of a physician.51Inpatient PsychiatricFacilityA facility that provides inpatient psychiatric services for the diagnosis and treatment ofmental illness on a 24-hour basis, by or under the supervision of a physician.52Psychiatric Facility-PartialHospitalizationA facility for the diagnosis and treatment of mental illness that provides a plannedtherapeutic program for members who do not require full time hospitalization, but whoneed broader programs than are possible from outpatient visits to a hospital-based orhospital-affiliated facility.53Community MentalHealth CenterA facility that provides the following services: outpatient services, including specializedoutpatient services for children, the elderly, individuals who are chronically ill, andresidents of the CMHC's mental health services area who have been discharged frominpatient treatment at a mental health facility; 24 hour-a-day emergency care services;day treatment, other partial hospitalization services, or psychosocial rehabilitationservices; screening for members being considered for admission to state mentalhealth facilities to determine the appropriateness of such admission; and consultationand education services.54Intermediate CareFacility/ Individuals withIntellectual DisabilitiesA facility which primarily provides health-related care and services above the level ofcustodial care to individuals but does not provide the level of care or treatmentavailable in a hospital or SNF.55Residential SubstanceAbuse Treatment FacilityA facility which provides treatment for substance (alcohol and drug) use to live-inresidents who do not require acute medical care. Services include individual andgroup therapy and counseling, family counseling, laboratory tests, drugs, andsupplies, psychological testing, and room and board.11 Tips for Completing the CMS-1500 Version 02/12 Claim Form

PlaceofServiceCode(s)Place of ServiceNamePlace of Service Description56Psychiatric ResidentialTreatment CenterA facility or distinct part of a facility for psychiatric care which provides a total 24-hourtherapeutically planned and professionally staffed group living and learningenvironment.57Non-ResidentialSubstance AbuseTreatment FacilityA location which provides treatment for substance (alcohol and drug) use on anambulatory basis. Services include individual and group therapy and counseling,family counseling, laboratory tests, drugs and supplies, and psychological testing.(Effective October 1, 2003)58-59UnassignedN/AMass ImmunizationCenterA location where providers administer pneumococcal pneumonia and influenza virusvaccinations and submit these services as electronic media claims, paper claims, orusing the roster billing method. This generally takes place in a mass immunizationsetting, such as, a public health center, pharmacy, or mall but may include a physicianoffice setting.61Comprehensive InpatientRehabilitation FacilityA facility that provides comprehensive rehabilitation services under the supervision ofa physician to inpatients with physical disabilities. Services include physical therapy,occupational therapy, speech pathology, social or psychological services, or orthoticand prosthetics services.62ComprehensiveOutpatient RehabilitationFacilityA facility that provides comprehensive rehabilitation services under the supervision ofa physician to outpatients with physical disabilities. Services include physical therapy,occupational therapy, and speech pathology services.63-64UnassignedN/A65 NotCovered byBeaconEnd-Stage RenalDisease TreatmentFacilityA facility other than a hospital, which provides dialysis treatment, maintenance, and/ortraining to members or caregivers on an ambulatory or home-care basis.66-70UnassignedN/A71State or Local PublicHealth ClinicA facility maintained by either state or local health departments that provideambulatory primary medical care under the general direction of a physician.72Rural Health ClinicA certified facility which is located in a rural medically underserved area that providesambulatory primary medical care under the general direction of a physician.73-80UnassignedN/A60NotCovered byBeacon12 Tips for Completing the CMS-1500 Version 02/12 Claim Form

PlaceofServiceCode(s)Place of ServiceNamePlace of Service Description81Independent LaboratoryA laboratory certified to perform diagnostic and/or clinical tests independent of aninstitution or a physician's office.82-98UnassignedN/A99Other Place of ServiceOther place of service not identified above. All data elements noted as required must be provided, but they must also be current and match what the subscriber’semployer/health plan has on file. If the member’s ID on the claim is illegible, or does not match what the subscriber’semployer/health plan has provided, we may not be able to determine the claimant. We strongly recommend that youobtain a copy of the member’s ID card, and validate that it is current at the time of each visit. There are times when supporting information is required to approve payment. If supporting documentation is notincluded, the claim may not be considered clean and may reject or deny. Claims that are not submitted on a CMS 1500 2012-02 or a UB04 often do not contain the information required toconsider the claim clean and may cause the claim to take a longer processing time. Claims submitted on outdatedclaim forms may be returned. Electronically submitted claims must also be in a HIPAA 5010 compliant format and conform to the Beaconcompanion guide to be considered clean. For more information on submitting electronic claims, please contact theEDI Helpdesk team at: 888-247-9311 or l helpful tips: DIAGNOSIS CODE: Place the diagnosis code as far left as possible within the box. REFERRING PROVIDER: If referring provider is an individual, use last name, first name, and middle initial.Middle initial is optional. If referring provider is a facility, provide the facility’s full name. P ATIENT RELATIONSHIP TO INSURED: When insured is different from patient and “Self” has been selected asthe relationship, the system will change the insured’s name to the patient’s name. INSURED’S ID: This field should contain insured’s ID and no additional information. RED & W HITE FORMS : Submitting claims in red and white forms, instead of black and white forms, ensuresbetter scanning quality.If you have questions about a specific claim rejection, contact the customer service department based on the member’s benefit plan.13 Tips for Completing the CMS-1500 Version 02/12 Claim Form

Tips for Completing the CMS-1500 Version 02/12 Claim Form 1 Tips for Completing the CMS-1500 Version 02/12 Claim Form As a Beacon provider partner, we value the se