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.

Medigap. A 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 those 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 explicitly 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 Medicare Services to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.

Note: Item 9d must be completed if a policy and/or group number is in item 9a.

Note: If a carrier assigned unique identifier of a Medigap insurer appears in item 9d, item 9c may be left blank.

If a participating provider of service or supplier and the patient wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in items 9, 9a, 9b, and 9d must be complete and accurate. Otherwise, you cannot forward the claim information to the Medigap insurer.

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: The appropriate information in item 11c is shown 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.

Insurance primary to Medicare: Circumstances under which Medicare payment may be secondary to other insurance include:

• Group Health Plan Coverage:
• Working Aged;
• Disability — (Large Group Health Plan); and
• End Stage Renal Disease,
• No Fault and/or Other Liability,
• Work-Related Illness/Injury:
• Workers' Compensation;
• Black Lung; and
• Veterans Benefits

Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) must be forwarded along with the claim form.

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.

Signature by Mark (X): Where an illiterate or physically handicapped enrollee signs by mark (X), a witness must enter his or her name and address next to the mark.

Note: This can be "Signature on File" and/or a computer generated signature.

Reminder: For date fields other than date of birth, all fields must 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.

Enter the name of the referring and/or ordering physician if the service or item was ordered or referred by a physician.

Referring Physician:
A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering Physician:
A physician who orders non-physician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. AlI claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician’s name and Unique Physician Identification Number (UPIN). This includes parenteral and enteral nutrition, immunosuppressive drug claims, and the following:

• Diagnostic laboratory services;
• Diagnostic radiology services;
• Portable x-ray services;
• Consultative services; and
• Durable medical equipment

Claims for other ordered/referred services not included in the preceding list must also show the ordering/referring physician's name and UPIN. For example, a surgeon must complete items 17 and 17a when a physician refers the patient. When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests), the performing physician's name and assigned UPIN must appear in items 17 and 17a.

All physicians who order or refer Medicare beneficiaries or services must obtain an UPIN, even though they may never bill Medicare directly. A physician who has not been assigned a UPIN must contact Medicare Services.

When a physician extender or other limited licensed practitioner refers a patient for consultative service, the name and UPIN of the physician supervising the limited licensed practitioner must appear in items 17 and 17a of the first claim form.

When a patient is referred to a physician who also orders and performs a diagnostic service, a separate claim form is required for the diagnostic service.

Enter the original ordering/referring physician's name and UPIN in items 17 and 17a of the first claim form.

Enter the ordering (performing) physician's name and UPIN in items 17 and 17a of the second claim form (the claim for reimbursement for the diagnostic service).

Surrogate UPINs: If the ordering/referring physician has not been assigned a UPIN, one of the surrogate UPINs listed below must be used in item 17a. The surrogate UPIN used depends on the circumstance and is used only until the physician is assigned a UPIN. Enter the physician's name in item 17 and the surrogate UPIN in item 17a. All surrogate UPINs, with the exception of retired physicians (RET000) are temporary and may be used only until a UPIN is assigned. Medicare Services will monitor claims with surrogate UPINs.

The term "physician," when used within the meaning of §1861(r) the Social Security 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

    

   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 (referred to in §1862(a)(4) of the Act) are furnished.

NOTE: Field17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

The drug's name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs. A concise description of an "unlisted procedure code" or a NOC code if one can be given within the confines of this box. Otherwise an attachment must be submitted with the claim. All applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.

The statement "Homebound" when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Services," and the Claims Processing Manual, Chapter 16, "Laboratory Services," and the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)

Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim.

Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.

When dental examinations are billed, the specific surgery for which the exam is being performed.

Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them. Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care. Enter the demonstration ID number "30" for all national emphysema treatment trial claims.

Enter the PIN (or NPI when effective) of the physician who is performing a purchased interpretation of a diagnostic test (see the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," for additional information). Report the interpreting physician’s PIN proceeded by a "PI" indicator (i.e., PI999999).

Note: This is a required field when billing for diagnostic tests subject to purchase price limitations.

All narrative diagnoses for non-physician specialties must be submitted on an attachment.

For physicians performing care plan oversight services, enter the 6-digit Medicare provider number (or NPI when effective) of the home health agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed.

The 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.

When a physician provides services to a beneficiary residing in a SNF and the services were rendered to a SNF beneficiary outside of the SNF, the physician should enter the Medicare facility provider number of the SNF in item 23.

A substituting physician under a reciprocal billing or locum tenens arrangement (mandated by statute §1842(b)(6)(D) of the Act) may be accommodated using item 23. The billing "absentee" physician’s Provider Identification Number (PIN) must continue to be reported in item 33 under solo practice arrangements and in item 24k under group practice arrangements.

Note: Item 23 can contain only one condition. Any additional conditions must be reported on a separate CMS1500 form.

Note: Claim is unprocessable if a date of service extends more than one day and a valid "to" date is not present.

Enter the specific procedure code must be shown without a narrative description. However, when reporting an "unlisted procedure code" or a NOC code, include a narrative description in item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. This is a required field.

Note: Claim is unprocessable if an "unlisted procedure code" or a "not otherwise classified" (NOC) code is indicated in item 24d, but an accompanying narrative is not present in Item 19 or on an attachment.

For anesthesia, the provider must indicate the elapsed time (minutes) in item 24g. Convert hours into minutes and enter the total minutes required for this procedure.

Suppliers must furnish the units of oxygen contents except for concentrators and initial rental claims for gas and liquid oxygen systems. Rounding of oxygen contents is as follows:

For stationary gas system rentals, suppliers must indicate oxygen contents in unit multiples of 50 cubic feet in item 24g, rounded to the nearest increment of 50. For example, if 73 cubic feet of oxygen were delivered during the rental month, the unit entry "01" indicating the nearest 50 cubic foot increment is entered in item 24g.

· For stationary liquid systems, units of contents must be specified in multiples of 10 pounds of liquid contents delivered, rounded to the nearest 10 pound increment. For example, if 63 pounds of liquid oxygen were delivered during the applicable rental month billed, the unit entry "06" is entered in item 24g.

· For units of portable contents only (i.e., no stationary gas or liquid system used), round to the nearest five feet or one liquid pound, respectively.

Note: This field should contain at least one day or unit.

The following providers of service/suppliers and claims can only be paid on an assignment basis:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services,
• Services of physician assistants, nurse practitioners, clinical nurse specialists,
• nurse midwives, certified registered nurse anesthetists, clinical psychologists, and
• clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services; and
• Drugs and biologicals.

Note: This is a required field, however, the claim can be processed if the following is true. 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 signature field has "Signature on file" and/or a computer generated signature.

Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.

Providers of service (namely physicians) shall identify the supplier's PIN when billing for purchased diagnostic tests. If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number. For durable medical, orthotic, and prosthetic claims, enter the PIN (of the location where the order was accepted) if the name and address was not provided in item 32 (DMERC only).

Suppliers billing the DMERC will use the National Supplier Clearinghouse (NSC) number in this field.

Enter the group PIN for the performing practitioner/supplier who is a member of a group practice.