BSB 699 1 CMS 1500 Claim Instructions

							                                                                                       BSB 699-1
SUBJECT
CMS-1500 Claim Form Instructions




Providers who submit claims on paper must use the new CMS-155 claim form effective May 23,
2007. The Big Sky Bonanza Services (BSB) program does not require information regarding
Medicare or the consumer’s health insurance (Third Party Liability -TPL). Medicare does not cover
and health insurances usually do not cover the services provided under the BSB. Below are
instructions for Medicaid-only claims. Consumer is the same as patient.


INSTRUCTIONS

1.        Not required.
1a.       Leave blank.
2.        Enter the client’s full name as it appears on the Medicaid card (last name first).
3.        Not required.
4.        Leave blank.
5.        Not required.
6-10.     Leave blank.
10d       Enter the client’s card control number as shown on the Montana Access to Health hard
          card or the client’s ID number available from one of the eligibility verification methods.
11.       Leave blank.
12.       Not required.
13-20     Leave blank.
21.       Enter diagnosis code(s). Only primary diagnosis is required.
22.       Leave blank.
23.       Enter the 10digit prior authorization number.
24.       Enter date(s) of service. mm/dd/yy format. Report only 6 lines on a claim.
24b.      Enter place of service (2 digit code).
24c.      Leave blank. (This field is now the emergency indicator–TOS is no longer on the claim.
24d.      Enter the appropriate procedure code and modifier(s).
24e.      Diagnosis code reference number (1,2,3, or 4) referring back to field 21.
24f.      Enter the total charge amount for this line. Do not put per unit amount.
24g.      Number of units or days.
24h-27.   Leave blank.
28.       Enter the total charges (sum of 24f).
29.       Leave blank unless another payer has made a payment on the services billed.


August 11, 2010                         Senior & Long Term Care                                Page 1 of 2
                                                                                 HCBS 699-2
SUBJECT
CMS-1500 Claim Form Instructions




30.       Leave blank.
31.       Signature of provider, authorized agent, facsimile (rubber stamp) signature, or a computer
          generated name. Signature date is required also.
32.       Leave blank.
33.       Enter the name, address (Zip + 4 is required), and phone number.

33a.      Enter NPI if you have a NPI and in:
          33b.   Enter Qualifier “ZZ” and taxonomy code (no spaces)
33b.      If you do not have a NPI, enter Qualifier “1D” and proprietary provider number. For
          example, 1D001234 (no spaces).


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August 11, 2010                          Senior & Long Term Care                         Page 2 of 2