1.3.- Las Fases de la Formación Docente
1.5 Las modalidades de la Formación Permanente del Profesorado
Paper:
Electronic:AMT01 F5 = Patient Paid Amount Qualifier 2300
AMT02 Patient Paid Amount
Leave blank. Not required by Medicare. nter the signa
Item 30
Item 31* E ture of the provider of service or supplier, or his
representative, and either a six-digit date (MM/DD/YY), eight-digit date (MM/DD/CCYY) or alphanumeric date (e.g., January 1, 2005) the form
as signed. w
Paper:
Electronic: Y = Signature on File 2300 CLM06N = Signature Not on File
In the case of a service that is provided “incident to” the service of a physician or non-physician practitioner, when the ordering physician o non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician
ractitioner shall be e
r
ntered in Item 31. When the ordering physician or on-physician practitioner is not supervising the service, enter the p
Note: This is a required field; however, the claim can be processed if a
physician, supplier or authorized person’s signature is missing, but the signature is on file; or if any authorization is attached to the claim; or if the
ignature field has “Signature on File” and/or a computer-generated
Item 32+ Enter the name, address and ZIP code of the service location for all
services other than those furnished in place of service home, 12. On the CMS-1500 form, only one name, address and ZIP code may be entered in the block. If additional entries are needed, separate claim forms
hall be submitted.
vice (namely physicians) shall identify the supplier’s name, ddress, ZIP code and NPI when billing for purchased diagnostic tests.
When more sup 00 to bill for
each supplie
T is d w s the work
at the physician’s office o
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. The cl st be by the beneficiary on a CMS-1490 form, not a C 00 fo
a modifier is billed, indicating the service was rendered in a Health the where the service was rendered shall be entered if other than home.
ix-
stic , the billing provider must, in addition to reporting its wn NPI on paper or electronically submitted Medicare claim (as the billing provider – Item 33), also report its own NPI as the performing provider with the name, address and ZIP code of the performing provider (Items 32 and 32a).
s signature. s roviders of ser P a than one r.
plier is used, use a separate CMS-15
his item complete hether the supplier’s personnel r at another location. perform aim mu MS-15 submitted rm. If
Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), physical location
If the supplier is a certified mammography screening center, enter the s digit FDA-approved certification number.
Note: When a provider bills for a mammography screening or diagno
services that have been purchased from a provider location in another contractor jurisdiction
Complete th office. If an
is item for all laboratory work performed outside a physician’s independent laboratory is billing, enter the place where the test as performed and the NPI.
Paper: w
onN 7
LI = Independent Lab, TL = Testing Lab Electr ic:
M101 7 = Service Location, FA = Facility, NM102 2 = Non-person Entity Type Qualifier NM103 Facility or Organization Name
N301 Address of Service Facility N401 City 2310D o 2420C r N402 State N403 ZIP code
Item 32a If required by Medicare claims processing policy, enter the NPI of the
service facility.
Note: When a provider bills for a mammography screening or diagnostic
services that have been purchased from a provider location in another contractor jurisdiction, the billing provider must, in addition to reporting its own NPI on paper or electronically submitted Medicare claim (as the billing provider – Item 33), also report its own NPI as the performing provider with the name, address and ZIP code of the performing provider (Items 32 and 32a).
Paper:
Electronic: NM108 XX =NPI Qualifier 2310D or 20C NM109 NPI Number 242400 PS101 Purchase Service Provider Identifier NM101 QB = Purchase Service Provider Qualifier NM108 XX = NPI Qualifier
2310C or
2420B NM109 NPI Number
REF01 EW = Mammography Certification Qualifier 2400
REF02 Mammogram Certification Number
Item 32b This field is no longer required by Medicare.
Item 33* Enter the pro ervi ame, address, ZIP code
nd telephone number.
nges thin certain time frames. This includes
changes to all addresses – practice address, correspondence and special payments address. All providers requesting a change of information must
n orm CMS-855). Letterhead is not permitted. The changed data must be
and
eactivation of Medicare billing privileges. The claim could be turned if the address in Item 33 does not match the provider file. For more information on the time frames and instructions for updating the
vider of s ce/supplier’s billing n a
Note: CMS requires providers/suppliers to notify Medicare of any cha
to their enrollment record wi
submit the changes on the appropriate Medicare enrollment applicatio (F
furnished in the appropriate application section of the CMS-855 form, the certification statement must contain an original signature and date of an authorized or delegated official currently on record with Medicare. Failure to report a change in a provider's or supplier's information may result in the d
TrailBlazer http://www.t
Provider Enrollment Web site at
railblazerhealth.com/Provider%20Enrollment/Default.aspx?Do mainID=1 or call (866) 539-5596 for J4 MAC states. Virginia providers should contact (866) 697-9670.
Paper:
NM101 85 = Billing Provider, 87 = Pay-to-Provider Electronic:
NM102 1 = Person, 2 = Non-person Entity
NM103 Provider of Service’s/Suppliers Billing Name N301 Address
N401 City N402 State
N403 ZIP code
PER03 TE = Telephone Number Qualifier 2010AA
or
2010AB
PER04 Telephone Number
Suppliers billing the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) will use the National Supplier Clearinghouse (NSC) number in this item.
Item 33a* Enter the NPI of the billing provider or group. This is a required field.
Note: Effective March 1, 2008, providers must include an NPI in the
primary provider fields (the billing, pay-to-provider and rendering provider fields), Items 24j and 33a. Claims submitted on or after March 1, 2008, without an NPI only or NPI combination in the primary provider fields will be rejected.
Paper:NM101 85 = Billing Provider, 87 = Pay-to-Provider