(Medicare Claims Processing Manual)

Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed.  Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the A/B MAC (B) or DME MAC to send Medicare claim information electronically.  If there is no such contract, the beneficiary must file his/her own supplemental claim.   Item 9a -  Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.   NOTE:   Item 9d must be completed, even when the provider enters a policy and/or group number in item 9a.  Item 9b -  Form version 08/05: Enter the Medigap insured's 8- digit birth date (MM | DD | CCYY) and sex.  Form version 02/12:  Leave blank.   Item 9c -  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.  For exampl e:  1257 Anywhere Street  Baltimore, MD 21204  is shown as "1257 Anywhere St.  MD 21204."   Item 9d -  Enter the Coordination of Benefits Agreement (COBA) Medigap -based Identifier (ID).  Refer to chapter 28, section 70.6.4, of this manual for more information.   Items 10a through 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 prim ary to Medicare.  Identify primary insurance information in item 11.  Item 10d -  Use this item exclusively for Medicaid (MCD) information.  If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD.  Item 11 -  THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD.  BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.   If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c.  Items 4, 6, and 7 must also be completed.   NOTE:   Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11.   If there is no insurance primary to Medicare, enter the word "NONE" and proceed to item 12.  If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to item 11b.  If a lab has collected previously and retained Medicare Secondary Payer (MSP) information for a beneficiary, the lab may use that information for billing purposes of the non-face- to-face lab service.  If the lab has no MSP information for the beneficiary, the lab will enter the word None in Block 11, when submitting a claim for payment of a reference lab service.  Where there has been no face- to-face encounter with the beneficiary, the claim will then follow the normal claims process.  When a lab has a face -to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.   Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:    Group Health Plan Coverage   o Working Aged;  o Disability (Large Group Health Plan); and  o End Stage Renal Disease;    No Fault and/or Other Liability; and    Work -Related Illness/Injury:   o Workers' Compensation;  o Black Lung; and  o Veterans Benefits.   NOTE:   For a paper claim to be considered for MSP benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.  (See Pub. 100- 05, Medicare Secondary Payer Manual, chapter 3.)   10.3 - Items 11a - 13 - Patient and Insured Information  (Rev.  3083, Issued: 10- 02-14, Effective: CMS -1500: 01- 06-14, ICD -10  Upon Implementation of ICD -10, Implementation: CMS -1500: 01- 06-14, ICD -10 - Upon Implementation of ICD -10)  Item 11a -  Enter the insured's 8- digit birth date (MM | DD | CCYY) and sex if different from item 3.   Item 11b -  Form version 08/05:  Enter employer's name, if applicable.  If there is a change in the insured's insurance 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.  Item 11c -  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.   Item 11d -  Leave blank.  Not required by Medicare.  Item 12 -  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 s ign 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, 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.   Item 13 -  The patients 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 wit h 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 patients signature or a signature on file is not required in order for Medicare payment to be made directly to the physician or supplier.   The presence of or lack of a signature or signature on file in this field will be indicated as such to any downstream coordination of benefits trading partners (supplemental insurers) with whom CMS has a payer -to-payer coordination of benefits relationship.  Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.  In addition, the signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions.  The patient or his/her authorized representative  signs this item or the signature must be on file as a separate Medigap authorization.  The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific.  It may state that the authorization applies to all occasions of service until it is revoked.  NOTE:  This can be "Signature on File" signature and/or a computer generated signature.   10.4 - Items 14 -33 - Provider of Service or Supplier Information  (Rev.10341, Issued: 09- 04-2020; Effective: 10- 06-20; Implementation: 10-  06-20)  Reminder:  For date fields other than date of birth, all fields shall be one or the other format, 6- digit:  (MM | DD | YY) or 8 -digit:  (MM | DD | CCYY).  Intermixing the two formats on the claim is not allowed.  Item 14 -  Enter either an 8 -digit (MM | DD | CCYY) or 6 -digit (MM | DD | YY) date of current illness, injury, or pregnancy.  For chiropractic services, enter an 8- digit (MM | DD | CCYY) or 6 -digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8 -digit (MM | DD | CCYY) or 6 -digit (MM | DD | YY) date in item 19.   Additional information for form version 02/12:  Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14.   Item 15 -  Leave blank.   Item 16 -  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.   Item 17 -  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 re port 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.   Additional instructions for form version 02/12:  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  Qualifier  Provider Role  DK  Ordering Provider  DQ  Supervising Provider   Enter the qualifier to the left of the dotted vertical line on item 17.   NOTE:   Under certain circumstances, Medicare permits a non -physician practitioner to perform these roles.  Refer to Pub 100- 02, Medicare Benefit Policy Manual, chapter 15 for non- physician practitioner rules.  Enter non- physician practitioner information accord ing to the rules above for physicians.   The term "physician" when used within the meaning of 1861(r)  of the Act and used in connection with performing any function or action refers to:   1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;   2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;   3. A doctor of podiatric medicine for purposes of (k), (m), (p)(1), and (s) and 1814(a) , 1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;   4. A doctor of optometry, but only with respect to the provision of items or services described in 1861(s)  of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or