ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 10 Section 10.3 Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan Claims Processing and Reimbursement Procedures HCFA 1500 Billing Instructions Page 1
10.3 HCFA 1500 Billing Instructions
Attached is a sample of the 1500 claim form and authorization letter. Below is a summary of which lines, codes, etc. that are required of the provider on the 1500 claim form. Line #1: Mark appropriate box. Medicare, Medicaid, etc. Line #1a: Insured’s I.D. Number. (Found on authorization letter- Member ID#) Line #2: Patient’s Name. (Member Name) Line #3: Patient’s Date of Birth and sex. Line #5: Patient’s Address. Line #6: Patient Relationship to Insured. Line #9: Complete that section if there is another insurance company. Line #10: If known. Line #10d: Patient’s Social Security Number. Line #12 & 13: Signature on file and current date. Line #21: ICD 9 Diagnostic Code Line #24a: Dates of Service. #24b: Place of Service #24d: AAM Billing Codes. #24f: Dollar amount of charges. #24g: Number of days/units being claimed. Line #25: Federal Tax ID Number. (SSN or EIN) Line #26: Patient’s Account Number. (Your organization’s consumer identifier.) Line #28: Total Charge. Line #29: Amount Paid. (Used if there is an ability to pay (ATP) or if another insurance company has made payment. Explanation of Benefits (EOB) from the other insurance company must be attached. Line #30: Balance Due. Line #31: Your signature and date. Line #32: Name and address where services were rendered. Line #33: Provider Name and address. Include Provider ID (PIN) as assigned by AAM. Please note that these instructions pertain ONLY to Access Alliance of Michigan billing.
Bay-Arenac Behavioral Health Access Alliance of Michigan Riverhaven Coordinating Agency
Huron Behavioral Health Montcalm Center for Behavioral Health Shiawassee County Community Mental Health Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 10 Section 10.3 Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan Claims Processing and Reimbursement Procedures HCFA 1500 Billing Instructions Page 2
Bay-Arenac Behavioral Health Access Alliance of Michigan Riverhaven Coordinating Agency
Huron Behavioral Health Montcalm Center for Behavioral Health Shiawassee County Community Mental Health Tuscola Behavioral Health Systems
ACCESS ALLIANCE OF MICHIGAN REGIONAL PROVIDER MANUAL
Chapter 10 Section 10.3 Bay-Arenac Behavioral Health Authority, Regional Pre-Paid Inpatient Health Plan Claims Processing and Reimbursement Procedures HCFA 1500 Billing Instructions Page 3
Bay-Arenac Behavioral Health Access Alliance of Michigan Riverhaven Coordinating Agency
Huron Behavioral Health Montcalm Center for Behavioral Health Shiawassee County Community Mental Health Tuscola Behavioral Health Systems