CMS-1500 BILLING INSTRUCTIONS Providers must use the CMS-1500 form to bill the Program. The CMS-1500 are available from the Government Printing Office, the American Medical Association; major medical oriented printing firm, or contact the US Government Printing Office at 202-512-1800 to place an order. Instructions for the completion of each of the CMS-1500 are provided in this section. See Section XVI - Appendix, page 72 for a reproduction of a CMS-1500 showing the reference numbers of Blocks. Blocks that refer to third party payers must be completed only if there is a third party payer other than Medicare or Medicaid. The Medical Assistance Program is by law the “payer of last resort”. If a recipient is covered by other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim. PROPER COMPLETION OF CMS-1500 For Medical Assistance processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed. Block 1 Show all type(s) of health insurance applicable to this claim by checking the appropriate box(es). Block 1a INSURED’S ID NUMBER – Enter the patient’s Medicare number if applicable. The patient’s (recipient’s) 11-digit Maryland Medical Assistance number is required in Block 9a. – Situational. Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Medical Assistance card. Block 3 PATIENT’S BIRTH DATE/SEX – Enter the patient’s (recipient’s) date of birth and sex. – Optional. Block 4 INSURED’S NAME (Last Name, First Name, Middle Initial) – Enter the name of the person in whose name the third party coverage is listed, only when applicable. – Optional. 5 PATIENT’S ADDRESS – Enter the patient’s (recipient’s) complete mailing address with zip code and telephone number. – Optional.
Block 6 PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party health insurance besides Medicare and Medicaid. – Optional. Block 7 INSURED’S ADDRESS – When there is third party health insurance coverage besides Medicare and Medicaid, enter the insured’s address and telephone number. – Optional. Block 8 PATIENT STATUS – No entry required. Block 9 OTHER INSURED’S NAME – No entry required. Block 9a OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the patient’s (recipient’s) 11-digit Maryland Medical Assistance number exactly as it appears on the MA card. The MA number must appear in this Block regardless of whether or not a recipient has other insurance. Medical Assistance eligibility should be verified on each date of service by calling EVS. EVS is operational 24 hours a day, 365 days a year at the following number: 1-866-710-1447- Required Block 9b OTHER INSURED’S DATE OF BIRTH – No entry required. Block 9c EMPLOYER’S NAME OR SCHOOL NAME – No entry required. 9d INSURANCE PLAN OR PROGRAM NAME – Enter the insured’s group name and group number only when there is third party health insurance coverage besides Medicare and Medicaid. – Optional. 10a IS PATIENT’S CONDITION RELATED TO - Check “Yes” or “No” to thru 10c indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Item 24, if this information is known. If not known, leave blank. – Optional. Block 10d RESERVED FOR LOCAL USE – When billing for abortions or abortion related service, enter the appropriate two-alpha character (AA-AH) condition code from the table below. This field should ONLY BE USED for abortions and abortion related services, otherwise leave blank. AA(a) Abortion Performed due to Rape Code indicates abortion performed due to a rape. AB(a) Abortion Performed due to Incest Code indicates abortion performed due to an incident of incest. AC(a) Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality Code indicates abortion performed due to a genetic defect, a deformity, or abnormality to the fetus.
PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS Billing a CMS-1500 with a Medicare EOMB: On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines. When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB. Dates of service must match Procedure codes must match Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB. Claims that have more then six lines, write “con’t” in Block #28 of each CMS-1500 and total all the lines on the last CMS-1500 claim. When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. Write in bold letters “Medicare EOMB” on each claim. In order for MA to make the necessary payments, the CMS-1500 and the Medicare EOMB must be submitted. Claims should be sent to the original claims address: Medical Assistance
HOW TO FILE AN ADJUSTMENT REQUEST If you have been paid, but paid incorrectly for a claim or received payment from a third party after Medical Assistance has made payment, you must complete and submit an Adjustment Request Form (DHMH 4518A) to correct the payment. See Section XVIII- Appendix, page 73 for an example of the DHMH 4518A. If an incorrect payment was due to a keying error made by Medical Assistance, or you billed the incorrect number of units, you must complete an Adjustment Request Form following the directions on the back of the form. When completing the Adjustment Form, do not bill only for remaining unpaid amounts or units, bill for entire amount(s). Example: You submitted and received payment for units, but you should have billed for five units. Do not bill for the remaining two units; bill for the full five units. Total Refunds – If you receive an incorrect payment, return the check issued by the Medical Assistance Program only when every claim payment listed on the remittance advice is incorrect, i.e., none of the recipients listed are your patients. When this occurs, return with a copy of the remittance advice and the check with a complete Adjustment Request Form to the address on the bottom of the form. Partial Refunds – If you receive a remittance advice, which lists some correct payments and some incorrect payments do not return the Medical Assistance Program check. Deposit the check and file an Adjustment Request Form for each individual claim paid incorrectly. NOTE: For overpayments or refunds, the provider may issue and submit one check to cover more than one Adjustment Request Form.
DURABLE MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT Maryland Medicaid updates the DMS/DME Approved List of Items on the same schedule as Medicare. The items on the Approved List of Items are covered as long as the items requested are deemed medically necessary. It is important that you review the current list to ensure that you are using the correct procedure code when requesting prepayment authorization (form DHMH-4527) and direct billing DMS/DME items. Before requesting prepayment authorization, ensure that the procedure codes require prepayment authorization by referring to the “PA” column on the Approved List of Items. It is also important to make sure that miscellaneous procedure codes are not used when there is an available code for that item. Additionally, DMS items should be requested on different prepayment authorization forms. These errors will cause a delay in processing your request. If the request has been approved, place the prepayment authorization number in Block #23 of the CMS-1500 form. All the information entered on the claim must correspond to the information on the approved prepayment authorization. Separate claims based on items that require authorization. Submit items that do not require authorization on a different CMS-1500 form. When billing for disposable medical supplies, indicate the number of units in Block #24G based on the pricing units stipulated in the Approved List of Items. Use of Modifiers: When billing for rentals, use modifier “RR”. Any rentals beyond three (3) months require prepayment authorization. When billing for new equipment, use “NU”. When billing for used equipment use “UE”, which requires prepayment authorization. NOTE: The column referred to as “Medicare Coverage” indicates whether Medicare covers that particular item. A block that is blank indicates that Medicare either covers the item with special coverage instruction or it is up to the MME Regional Carrier’s (DMERC) discretion. Please visit if you have questions or concerns about these policies, or would like a copy of the Approved List of Items. Also available is the prepayment authorization form (DHMH-4527), provider memos/transmittals, and access to the DMS/DME regulations (COMAR 10.09.12). If you prefer to speak with a Staff Specialist, call 410-767-1739.
IMPORTANT TELEPHONE NUMBERS AND ADDRESSES The Department’s website will contain up-to-date information relative to Maryland Medicaid Programs, physician’s fee schedule and program transmittals. Providers can access the website via the following address: The Department of Health and Mental Hygiene (DHMH) has developed a new website called eMedicaid . This website is an interactive site that allows providers to: Enroll as a Medicaid Provider Add new providers to practice Obtain payment information by downloading copies the remittance advices for up 2 years Access EVS to verify recipient eligibility Submit claims electronically for faster payment Check the status of claims It is recommended that the office administrator register all users for this site. Claims – Originals 410-767-5347 Claims – Adjustments 410-767-5346 Eligibility Verification System (EVS) 1-866-710-1447 Forms – How to Order Forms Office of Systems, Operations & Pharmacy , Room SS-12