Sample Cms 1450 Form For Claims

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Sample CMS 1450 Form for Claims
Submitted by Hospital Outpatient Departments
1. Revenue Codes and Descriptions (Boxes 42 and 43):
__
__
__
Box 42 and 43 requirements vary by payer.
4
TYPE
1
2
3a PAT.
OF BILL
CNTL #
b. MED.
Contact JETREA CARE for guidance on specific payer requirements.
REC. #
6
STATEMENT COVERS PERIOD
7
5 FED. TAX NO.
FROM
THROUGH
8 PATIENT NAME
a
9 PATIENT ADDRESS
a
2. Product Code (Box 44):
b
b
c
d
e
ADMISSION
CONDITION CODES
29 ACDT 30
10 BIRTHDATE
11 SEX
16 DHR
17 STAT
12
DATE
13 HR 14 TYPE 15 SRC
18
19
20
21
22
23
24
25
26
27
28
STATE
Enter the appropriate product code, as required by payer. For example:
31
OCCURRENCE
32
OCCURRENCE
33
OCCURRENCE
34
OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
J3490 (Unclassified drug) OR
CODE
DATE
CODE
DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE
FROM
THROUGH
J3590 (Unclassified biologic) OR
C9298 (Injection, Ocriplasmin, 0.125 mg)
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
CODE
AMOUNT
CODE
AMOUNT
CODE
AMOUNT
a
Contact JETREA CARE for guidance on specific payer requirements.
b
c
d
3. Units (Box 46):
42 REV. CD.
43 DESCRIPTION
44 HCPCS / RATE / HIPPS CODE
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
Enter appropriate units for the code listed in Box 44. For example:
2
2
3
3
J3490 or J3590 – 1 billing unit for a single-use vial
4
4
C9298 – 4 billing units for a single-use vial
5
5
6
6
7
7
4. Procedure Code (Box 44):
8
8
9
9
10
10
CPT code for intravitreal injection and appropriate modifier:
11
11
67028-RT (Intravitreal injection of a pharmacological agent); right eye OR
12
12
67028-LT (Intravitreal injection of a pharmacological agent); left eye
13
13
14
14
15
15
16
16
5. Diagnosis Code (Box 67):
17
17
18
18
Enter the appropriate ICD-9-CM diagnosis code. For example:
19
19
20
20
379.27 (Vitreomacular adhesion, vitreomacular traction)*
21
21
22
22
PAGE
OF
TOTALS
*Excludes: traction detachment with vitreoretinal organization (361.81).
CREATION DATE
23
23
.
52 REL
53 ASG.
50 PAYER NAME
51 HEALTH PLAN ID
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
INFO
BEN.
A
A
57
6. Product Information (Box 80):
B
OTHER
B
PRV ID
C
C
Box 80 requirements vary by payer.
58 INSURED’S NAME
59 P . REL 60 INSURED’S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A
A
Contact JETREA CARE for guidance on specific payer requirements.
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
General Tips for Clean Claim Submission
A
A
Submit accurate and complete patient information
B
B
C
C
Follow payer requirements for punctuation and character limits for electronic claim submission
67
A
B
C
D
E
F
G
H
66
68
DX
I
J
K
L
M
N
O
P
Q
Promptly submit claims within the timeframe set by the payer
a
b
c
69 ADMIT
70 PATIENT
71 PPS
72
73
DX
REASON DX
CODE
ECI
74
PRINCIPAL PROCEDURE
a.
OTHER PROCEDURE
b.
OTHER PROCEDURE
75
QUAL
Proactive Steps to Facilitate Prompt Claim Through JETREA CARE
76 ATTENDING
NPI
CODE
DATE
CODE
DATE
CODE
DATE
LAST
FIRST
Identify specific payer coding requirements (eg, J3490, J3590, or C9298)
c.
OTHER PROCEDURE
d.
OTHER PROCEDURE
e.
OTHER PROCEDURE
77 OPERATING
NPI
QUAL
CODE
DATE
CODE
DATE
CODE
DATE
LAST
FIRST
Determine if precertification or prior authorization
81CC
80 REMARKS
78 OTHER
NPI
QUAL
a
is required before service can be rendered
b
LAST
FIRST
(ocriplasmin)
Follow payer instructions if supplemental or additional
c
79 OTHER
NPI
QUAL
Intravitreal Injection, 2.5 mg/mL
d
FIRST
LAST
documentation is requested (eg, FDA approval letter, invoice, etc)
C A R E
UB-04 CMS-1450
APPROVED OMB NO.
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
National Uniform
Billing Committee
LIC9213257

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