Billing and Authorization (Maryland providers)
Help with ICD-9 coding
CMS 1500 Required Fields
Box Number
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Required Information
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1.a.
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Insured's ID Number
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2.
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Patient's Name
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3.
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Patient's Birth Date
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4.
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Insured's Name
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5.
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Patient's Address
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6.
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Patient Relationship To Insured
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7.
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Insured's Address
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9.a.
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Other Insured's Name (N/A if not applicable)
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9.b.
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Other Insured's Policy Or Group No.
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9.c.
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Employer's Name Or School Name
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9.d.
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Insurance Plan Name Or Program Name
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11.a.
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Insured's Date Of Birth
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11.b.
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Employer's Name Or School Name
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11.c.
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Insurance Plan Name Or Program Name
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11.d.
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Is There Another Health Benefit Plan?
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12.
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Patient's Or Authorized Person's Signature (or indicate signature on file)
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13.
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Insured's Or Authorized Person's Signature (or indicate signature on file)
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21.
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Diagnosis Or Nature of Illness Or Injury
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23.
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Prior Authorization Number
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24.A.
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Date(s) Of Service
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24.B.
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Place Of Service
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24.C.
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Type Of Service
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24.D.
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Procedures, Service Or Supplies (CPT/HCPCS)
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24.E.
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Diagnosis Code
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24.F.
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Charges
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24.G.
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Days Or Units
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25.
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Federal Tax ID Number
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31.
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Signature Of Physician Or Supplier, Including Degrees Or Credentials
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32.
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Name and Address Of Facility Where Services Were Rendered
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33.
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Physician's, Supplier's Billing Name, Address, Zip Code and Phone Number
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