(Medicare Claims Processing Manual)

D. Services/Pricing Units  - (CWFB_MTUS_IND_CD = 3)   For claims reporting a service or pricing unit, the following examples should be used to code the line item:  Example 1:  A total of 2 visits was reported for HCPCS code 99211:  Office or other outpatient visit for the management of an established patient.   Number of services:  2 MTUS (services):  2 MTUS indicator:  3  Example 2:  A total of 500 milligrams was administered for HCPCS code J0120:  Injection, Tetracycline, up to 250 mg.  NOTE :  The number of milligrams should not be reported in the service or MTUS fields.  Instead, report the number of pricing units.  In this case, up to 250 mg equals 1 unit/service.  Thus, 500 mg equals 2 units/services.  Number of services:  2 MTUS (services):  2 MTUS indicator:  3  Example 3:  A total of 24 cans was purchased, each containing 300 calories for HCPCS code B4150:  Enteral Formulae, 100 calories.   NOTE :  Neither number of cans nor the number of calories should be reported in the services or MTUS fields.  Instead, report the number of pricing units.  In this case, 100 calories equals 1 unit/service.  Thus, 24 cans * 300 calories / 100 calories equals 72 uni ts/services.   Number of services:  72 MTUS (services):  72 MTUS indicator:  3  E. Oxygen Services  - (CWFB_MTUS_IND_CD = 4)   For claims reporting oxygen units, the following example should be used to code the line item:  A total of 2 allowed services was reported for HCPCS code E0441:  Oxygen contents, gaseous, 1 months supply = 1 unit.  The claim reported a 2 months supply of oxygen.  Number of services:  2 MTUS:  2 MTUS indicator:  4  F. Blood Services  - (CWFB_MTUS_IND_CD = 5)   For claims reporting blood units, the following example should be used to code the line item:  A total of 6 units of blood (services) was furnished for HCPCS code P9010:  Blood (whole), for transfusion, per unit.  Two units were denied .  Number of services:  6 (furnished)  MTUS (units):  4 (allowed)  MTUS indicator:  5  20 - Patients Request for Medica l Payment Form CMS -1490S  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  The CMS implemented a new version of the Form CMS -1490S effective January 1, 2019. The revised form is version 01/18, OMB control number 0938- 1197. The revised form will replace the previous version of the form 01/05, OMB control number 0938-0999.   The term, Form CMS -1490S refers to the form generically, independent of a given version. Medicare will conduct a dual -use period (January 1, 2019 through March 31, 2019) during which Beneficiaries (or their representatives) can send Medicare claims on either the old or the revised form. When the dual -use period is over, Medicare will accept beneficiary paper claims on only the revised Form CMS -1490S, version 01/18.   This form is used only by beneficiaries (or their representatives) who complete and file their own claims.  It contains the patients comparable items of data that are on the Form CMS -1500.  When the Form CMS -1490S is used, an itemized bill must be submitt ed with the claim.  Some enrollees may want to keep the original itemized physician and supplier bills for income tax or complementary insurance purposes.  Photocopies of itemized bills are acceptable for Medicare deductible and payment purposes if there i s no evidence of alteration.  Social Security offices use the Form CMS -1490S when assisting beneficiaries in filing Part B Medicare claims.   Although 1848(g)(4)  of the Act requires physicians and suppliers to submit Part B Medicare claims for services furnished on or after September 1, 1990, contractors continue to accept, process, and pay for covered services submitted by beneficiaries on a Form CMS -1490S if the re is no clear indication that the service provider intends to file a claim.  An itemized bill for services on or after September 1, 1990, which clearly indicates the physician or supplier intends to file a Part B claim for the patient, may be returned to the beneficiary.   For Medicare covered services received on or after September 1, 1990, the Form CMS -1490S is used by beneficiaries to submit Part B claims only if the service provider refuses to do so or if one of the following situations applies:    DME purchases from private sources;    Cases in which a physician/supplier does not possess information essential for filing an MSP claim.  Assume this is the case if the beneficiary files an MSP claim and encloses the primary insurer's payment determination notice and there is no indication that the service provider was asked to file but refused to do so;    Services paid under the indirect payment procedure;    Foreign claims;    Services furnished by sanctioned physicians and suppliers which are approved for payment to the beneficiary per the Program Integrity Manual (PIM); and    Other unusual or unique situations that are evaluated on a case -by-case basis.   If the contractor approves 11 or more Form CMS -1490S claims in a calendar month for services performed on or after September 1, 1990, by the same physician or supplier, monitor the provider's claims submissions and take appropriate action.  The contractor continues to stock Form CMS -1490S and, upon request, furnish beneficiaries with these forms. (Beneficiaries need these forms to file claims for services that physicians/suppliers are not required to submit (e.g., services prior to September 1, 1990), or refuse to submit to Part B on their behalf.)   30 - Printing Standards and Print File Specifications Form CMS -1500 (Rev. 899, Issued:  03- 31-06; Effective:  10 -01-06; Implementation:  10 -02-06)  The National Uniform Claims Committee (NUCC) has approved the printing standards for Form CMS -1500 (08- 05) paper claim.  These standards are as follows:   The Form CMS -1500 (08- 05) is designed to accommodate 10- pitch Pica type, 6 lines per inch vertical and 10 characters per inch (cpi) horizontal.  Once adjusted to the left and right, PICA Alignment blocks in the first print line and characters appear within form lines as shown in the print file matrix.   Also provided on the Form CMS -1500 (08- 05) is a position bar.  This is a thick horizontal line that is at the base of the PICA alignment Boxes.   The Form CMS -1500 (08- 05) is used in four different styles.  Any one of these four styles may be printed from two negatives in concurrence with the layout that was approved by the NUCC.  The face/back negative furnished must be used for all parts.   Compliance with these standards is required to facilitate the use of image processing technology such as Optical Character Recognition (OCR), facsimile transmission, and image storing.  Cut Sheet:   Size -  8.5 by 11 inches (plus or minus .0625 inch) or 217mm by 279mm (plus or minus 2mm).   Print  - Face and back, head to head.   Margins  -   Face -  The top margin from the top edge of the form to the first print position is 1.33 inches or 34mm.  The left margin is 0.3 inches to the left end of the first print position.   Back -  0.25 inch head and foot, 0.25 inch left and right or 6.35 mm head and foot, 6.35 mm left and right.   Offset -  The X and Y offset for margins must not vary by more than +/ -0.1 inch or 2.54 mm from sheet to sheet.   The X  offset refers to the horizontal distance from the left edge of the paper to the beginning of the printing.  The Y  offset refers to the vertical distance between the top of the paper and the beginning of the printing.  Askewity -  The askewity of the printed image must be no greater than 0.15mm in 100mm.  Paper Stock  - Basis weight 20# recycled 30% postconsumer waste, White Environmental Paper Alliance (EPA) or approved paper stock.  Smoothness:  FS to be (140- 160), or equivalent stock.   Ink color  -   Face -  (OCR -Red Ink) must be in Flint J -6983 Red OCR dropout ink or an exact match, formerly known as Sinclair Valentine).  There is to be no contamination with Black ink or pigment.  Printer must maintain proper ink reflections limits of the OCR reader specified by the purchaser.   Back -  Same as face.   Titles -  Color of any titles if applicable:  Are to be in the same ink as the form, Flint J6983 OCR Red dropout ink.  Symbol -  The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink.  Two Part Snap -set:  Size -  Dimensions are same as Cut Sheet (detached 8.5 by 11 inches), plus top stub (.5 to .75 inches).   Print  -   Part 1 -  Face and back - head to head.   Part 2 -  Face and back - head to head.   Margins  - Same as Cut Sheet.   Askewity  - Same as Cut Sheet.   Stock  -   Part 1 -  Carbonless, 20 CB -  Recycled White   Part 2 -  Any color that will not interfere with scanning of Part 1 sheet.   Ink Color  -  Part 1 -  (OCR -Red Ink) must be in Flint J -6983 Red OCR dropout ink or an exact match.   Part 2 -  Any color that will not interfere with scanning of Part 1 sheet.   Titles -  Color of any titles if applicable:  Are to be in the same ink as the form, Flint J6983 OCR Red dropout ink.  Symbol -  The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink.  Perforations  - Perforate top stub for disassembly of parts.   One Part Marginally Punched Continuous Form:   Size -  Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11 inches, detached: 8.5 by 11 inches).   Print  - Face and back, head to head.   Margins  - On detached sheet, same as for Cut Sheet.   Askewity  - On detached sheet, same as for Cut Sheet.   Paper Stock  - Same as for Cut Sheet.   Ink Color  - Same as for Cut Sheet (OCR -Red Ink) must be in Flint J -6983 Red OCR dropout ink or an exact match.  Titles -  Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red dropout ink.  Symbol -  The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink.  Perforations  - Marginally 0.5 inch left and right, tear line horizontally every 11 inches.   Two Part Marginally Punched Continuous Forms:   Size -  Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11 inches, detached: 8.5 by 11 inches).   Print  -   Part 1 - Face and back, head to head.   Part 2 - Face and back, head to head.   Margins  - On detached sheet, same as for Cut Sheet.   Askewity  - On detached sheet, same as for Cut Sheet.   Paper Stock -    Part 1 -  Carbonless, 20 CB -  Recycled White   Part 2 -  Any color or weight that does not interfere with scanning of part 1 sheet. Suggest the following sequence:   Paper Weight:   1st part is 20 CB -  OCR Bond   2nd part is 14 CFB (if not last part)   Last part is 15CF   CB = Coated Back (Carbonless black print)   CFB = Coated Front and Back (Carbonless black print)