17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 1B ABC1234567890
RALPH SMITH MD 17b. NPI 0123456789
Description: The name of the referring Provider, ordering Provider, or other source who referred or ordered the service(s) or supply (s) on the claim. Do not use periods or commas within the name. A hyphen can be used for hyphenated names.
The Other ID number of the referring Provider, ordering Provider, or other source is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a. The non-NPI ID number of Rev 12/06
the referring Provider, ordering Provider, or other source refers to the payer assigned unique identifier of the professional. The NUCC defines the following qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
0B State License Number G2 Provider Commercial Number 1B BlueShield Provider Number G2 LU Location Number
1C Medicare Provider Number N5 Provider Plan Network ID Number
1D Medicaid Provider Number SY Social Security Number (may not be used for Medicare 1G Provider UPIN Number X5 State Industrial Accident Provider Number
1H CHAMPUS/TRICARE ID Number ZZ Provider Taxonomy E1 Employer’s ID Number
Enter the NPI number of the referring Provider, ordering Provider, or other source in 17b.
Print Specs: Line 29, Columns 2-27 and 29-48.
Columns 2-27 — enter name, left justify, ALL CAPITAL LETTERS Columns 29-48 — enter UPIN. left justify, six positions, alphanumeric
BLOCK 18 — HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICESMM DD CCYY MM DD CCYY FROM 02 15 2006 TO 02 17 2006
Description: Enter the applicable month, day and year of the hospital admission and discharge using an eight (8)-digit date format. This block is to be completed when medical services are rendered as a result of, or subsequent to, a related hospitalization. If services were rendered in a facility other than the patient’s home or a physician’s office, provide the name and address of that facility in Block 32.
Print Specs: Line 29, Columns 54, 55, 57, 58, 60, 61, 68, 69, 71, 72, 74, and 75.
BLOCK 19 — RESERVED FOR LOCAL USE
19. RESERVED FOR LOCAL USECORRECTED BILL
Description: Use this block when submitting corrected bills. Write, stamp or type “CORRECTED BILL” in Block 19. It is important to keep the text within the boundaries of the field. Extending the type beyond the block may result in errors and delay processing of the claim.
BLOCK 20 — OUTSIDE LAB? $CHARGES
20. OUTSIDE LAB? $ CHARGESYES NO
Description: Indicate whether any diagnostic tests subject to purchase price limitations were performed outside the physician’s office, and enter the charges for those purchased services. Place an “X” in the “YES” box when a provider other than the provider billing for the service performed the diagnostic test. When “YES” is checked, Block 32 must be completed with the name and address of the clinical laboratory or other supplier that Rev 12/06
performed the service. If billing for multiple purchased diagnostic tests, each test must be submitted on a separate claim form. Enter the purchase price of the tests in the charges column. Show dollars and cents, omitting the dollar sign. Place an “X” in the “NO” box when diagnostic tests are performed in the physician's office or supervised by the physician (e.g., no purchased tests are included on the claim).
Print Specs: Line 31, Columns 52, 57, and 62-69.
If column 52 is used, then a value greater than 0 is required in columns 62-69. Print “X” in column 52 or 57, and numeric amount in columns 62-69.
BLOCK 21 — DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3, OR 4 TO ITEM 24E BY LINE)1. l_005 .80 3. l__________.___
2. l_536 . 80 4. l__________.___
Description: Enter up to four (4) ICD-9-CM codes for the diagnoses, conditions, problems or other reasons for the encounter or visit. All physician specialties must use an ICD-9-CM code number and code up to the highest level of specificity. Report at least one diagnosis code on the claim. You may report up to four (4) codes in order of priority (primary, secondary conditions, etc.) to accurately describe the reason for the encounter. List first the code for the diagnosis, condition, problem, etc., shown in the medical record to be chiefly responsible for the service provided, then list codes that describe co-existing conditions. Relate lines 1, 2, 3, 4 to the lines of service in Block 24E by line number. (If multi-page claim, list diagnosis code(s) for all conditions related to patient’s illness on each page.)
Print Specs: Line 33, Columns 3, 4, 5, 7, 8. Line 35, Columns 3, 4, 5, 7, 8. Line 33, Columns 31, 32, 33, 35, 36. Line 35, Columns 31, 32, 33, 35, 36. Zero fill from the left, alphanumeric.
BLOCK 22 — MEDICAID (TENNCARE) RESUBMISSION
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
Description: This item contains the acronym “CC” denoting that it is a “corrected claim”. When billing Medicare, leave this item blank.
BLOCK 23 — PRIOR AUTHORIZATION NUMBER
23. PRIOR AUTHORIZATION NUMBER009876
Description: Enter the prior authorization number(s) assigned by the HMO/BHO for appropriate procedures.
Print Specs: Line 35, Columns 50-78.
Print alphanumeric,
Left justify.
BLOCK 24 – SUPPLEMENTAL INFORMATION
The following lists qualifier codes and description of supplemental information that can be entered in the shaded lines of Block 24:
Anesthesia information
ZZ Narrative description of unspecified code N4 National Drug Codes (NDC)
Description: To enter supplemental information, begin at 24A by entering the qualifier and then the
information. Do not enter a space between the qualifier and the
number/code/information. Do not enter hyphens or spaces within the number/code. More than one supplemental item can be reported in the shaded lines of Block 24. Enter the first qualifier and number/code/information at Block 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information. The following qualifiers are to be used when reporting NDC units:
F2 International Unit ML Milliliter
GR Gram UN Unit
Note: Supplemental information entered in shaded area will be ignored if a valid qualifier does not precede the data.
The following examples define how to enter different types of supplemental information in Block 24. These examples demonstrate how the data are to be entered into the fields and are not meant to provide direction on how to code for certain services:
Example 1: Anesthesia Services, when payment based on minutes as units
Example 2: Anesthesia Services, when payment based on 15-minute units
Example 3: Unspecified Code
Example 4: NDC Code
BLOCK 24A. – 24E. —DATE(S) OF SERVICE, PLACE OF SERVICE, EMG,
PROCEDURES, SERVICES OR SUPPLIES, DIAGNOSIS POINTER
24 A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES E. DIAGNOSIS POINTER 03 06 05 03 10 05 1