evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Providers and suppliers have the option of entering either a 6 or 8 -digit date in items 11b, 14, 16, 18, 19, or 24a.  However, if a provider of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8- digit dates for all  these fields.  For instance, a provider of service or supplier will not  be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6- digit date for item 24a.  The same applies to providers of service and suppliers who choose to submit 6 -digit dates too.  Items 12 and 31 are exempt from this requirement.  Legend  Description  MM Month (e.g., December = 12)  DD Day (e.g., Dec15 = 15)  YY 2 position Year (e.g., 1998 = 98)  CCYY  4 position Year (e.g., 1998 = 1998)  (MM | DD | YY) or (MM | DD | CCYY)  A space must be reported between month, day, and year (e.g., 12 | 15 | 98 or 12 | 15 | 1998).  This space is delineated by a dotted vertical line on the Form CMS -1500)  Legend  Description  (MMDDYY) or (MMDDCCYY)  No space must be reported between month, day, and year (e.g., 121598 or 12151998).  The date must be recorded as one continuous number.   10.1 - Claims That are Incomplete or Contain Invalid Information  (Rev. 145, 04- 23-04)  If a claim is submitted with incomplete or invalid information, it may be returned to the submitter as unprocessable.  See Chapter 1 for definitions and instructions concerning the handling of incomplete or invalid claims.  10.2 - Items 1 -11 - Patient and Insured Information  (Rev. 4232, Issued: 02- 08-19, Effective: 03 -12-19, Implementation: 03- 12-19)
(Medicare Claims Processing Manual)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Item 1 -  Shows the type of health insurance coverage applicable to this claim by the appropriately checked box; check the Medicare box.   Item 1a -  Enter the patient's Medicare beneficiary identifier whether Medicare is the primary or secondary payer.  This is a required field.  Item 2 -  Enter the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card.  This is a required field.  Item 3 -  Enter the patient's 8- digit birth date (MM | DD | CCYY) and sex.   Item 4 -  If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here.  When the insured and the patient are the same, enter the word SAME.  If Medicare is primary, leave blank .  Item 5 -  Enter the patient's mailing address and telephone number.  On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.   Item 6 -  Check the appropriate box for patient's relationship to insured when item 4 is completed.   Item 7 -  Enter the insured's address and telephone number.  When the address is the same as the patient's, enter the word SAME.  Complete this item only when items 4, 6, and 11 are completed.   Item 8 -  Form version 08/05:  Check the appropriate box for the patient's marital status and whether employed or a student.  Form version 02/12:  Leave blank.   Item 9 -  Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2.  Otherwise, enter the word SAME.  If no Medigap benefits are assigned, leave blank.  This field may be used in the future for supplemental insurance plans.
(Medicare Claims Processing Manual)
NOTE:   Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the participating physician or supplier.  Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary.  Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients.  A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer.  (See chapter 28.)   Medigap -  Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in 1882(g)(1)  of title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute.  It is a health insurance policy or other health benefit plan offered by a private entity to th ose persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits.  It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare.  It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage.  Also, it expl icitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.   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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets  uniform minimum standards specified by the Secretary, but only for purposes of 1861(s)(1) and 1861(s)(2)(A)  of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).  For the purposes of 1862(a)(4)  of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referr ed to in 1862(a)(4) of the Act) are furnished.   Referring physician  - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.   Ordering physician  - is a physician or, when appropriate, a non -physician practitioner who orders non- physician services for the patient.  See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15 for non- physician practitioner rules.  Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physicians or non- physician practitioners service.  The ordering/referring requirement became effective January 1, 1992, and is required by 1833(q)  of the Act.  All claims  for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name.  The following services/situations require the submission of the referring/ordering provider information:    Medicare covered services and items that are the result of a physician's order or referral;    Parenteral and enteral nutrition;    Immunosuppressive drug claims;    Hepatitis B claims;   Diagnostic laboratory services;    Diagnostic radiology services;    Portable x -ray services;    Consultative services;    Durable medical equipment;    When the ordering physician is also the performing physician (as often is the case with in -office clinical laboratory tests);
(Medicare Claims Processing Manual)
 Diagnostic radiology services;    Portable x -ray services;    Consultative services;    Durable medical equipment;    When the ordering physician is also the performing physician (as often is the case with in -office clinical laboratory tests);    When a service is incident to the service of a physician or non- physician practitioner, the name of the physician or non- physician practitioner who performs the initial service and orders the non -physician service must appear in item 17;   When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;   Effective for claims with dates of service on or after October 1, 2012, all claims for physical therapy, occupational therapy, or speech- language pathology services, including those furnished incident to a physician or nonphysician practitioner, require that the name and NPI of the certifying physician or nonphysician practitioner of the therapy plan of care be entered as the referring physician in Items 17 and 17b.  Item 17a -  Leave blank.   Item 17b -  Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17.  All physicians and non- physician practitioners who order services or refer Medicare beneficiaries must report this data.   NOTE:  Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.   Item 18 -  Enter either an 8 -digit (MM | DD | CCYY) or a 6 -digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.   Item 19  - Enter either a 6 -digit (MM | DD | YY) or an 8 -digit (MM | DD | CCYY) date patient was last seen and the NPI of his/her attending physician when a physician providing routine foot care submits claims.  NOTE:   Effective May 23, 2008, all provider identifiers submitted on the CMS -1500 claim form MUST be in the form of an NPI.