Item 1a

Enter the patient's Medicare number whether Medicare is the primary or secondary payer. This is a required field.

Item 4

If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.

Item 7

Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.

Item 9, 9a, 9b, 9c

Item 9 - Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in Item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave item 9 blank. Refer to the Claim Form Instructions for complete information.

Item 9a - Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP. Note: Item 9d must be completed if the provider enters a policy and/or group number in item 9a.

Item 9b - This field is not required.

Item 9c - This field is not required.

Items 10a - 10c, 10d

Items 10a through 10c - Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the state postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

Item 10d - Use this item exclusively for Medicaid information. If the patient is entitled to Medicaid, enter "MCD" followed by the patient's Medicaid number.

Items 11, 11a - 11c, 11d

Item 11 - THIS ITEM MUST BE COMPLETED. By completing this item, you acknowledge having made a good faith effort to determine whether Medicare is the primary or secondary payer. If there is no insurance primary to Medicare, enter the word "NONE". If there is insurance primary to Medicare, refer to the Claim Form Instructions for complete information.

Item 11a – 11c - Only required when Medicare is secondary payer. Refer to the Claim Form Instructions for complete information.

Item 11d - Leave blank. Not required by Medicare.

Item 12

The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. Refer to the Claim Form Instructions for complete information.

Item 13

The patient's signature on the statement "signature on file" in this item authorizes payment of medical benefits to you. The patient or his/her authorized representative signs this item or the signature must be on file separately with you as an authorization. However, note that when payment can only be made on an assignment-related basis or when payment is for services furnished by a participating supplier, a patient's signature or a "signature on file" is not required in order for Medicare payment to be made directly to you. Refer to the Claim Form Instructions for complete information.

Items 14, 15, 15

Item 14 - Leave blank. Not required by the DME MAC.

Item 15 - Leave blank. Not required by Medicare.

Item 16 - Leave blank. Not required by the DME MAC.

Items 17, 17a, 17b

Item 17 - Enter the "DK" qualifier to the left of the dotted vertical line, followed by the name of the ordering physician to the right of the dotted vertical line. All physicians who order services or refer Medicare beneficiaries must report this data. Refer to the Claim Form Instructions for complete information.

Item 17a - Leave blank.

Item 17b - Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

Item 18

Leave blank. Not required by the DME MAC.

Item 19

Enter additional information that may be needed for claim processing. Refer to the Claim Form Instructions for complete information.

Item 20

Leave blank. Not required by the DME MAC.

Item 21

Item 21 - Enter the patient's diagnosis/condition. You must use an ICD-10 code number and code to the highest level of specificity for the date of service. Enter up to 12 diagnoses in priority order. All narrative diagnoses for non-physician specialties must be submitted on an attachment.

Item 21 ICD Ind. - Enter "0" to indicate the ICD-10 code.

Items 22, 23

Item 22 - Leave blank. Not required by Medicare.

Item 23 - Leave blank. Not required by the DME MAC.

Items 24, 24A

Item 24 - The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.

Item 24A - Enter a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G. This is a required field.

Items 24B, 24C

Item 24B - Enter the appropriate place of service code(s), Identify the location, using a place of service code, for each item used or service performed. This is a required field. NOTE: For DMEPOS claims, the place of service is considered to be the place where the beneficiary will primarily use the DME POS item

Item 24C - Medicare providers are not required to complete this item.

Item 24D

Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding Systme (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The Form CMS-1500 (02-12) has the ability to capture up to four modifiers. If more than four modifiers are needed, use modifier 99 (overflow) as the fourth modifier and enter the additional modifiers in item 19.

Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (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. If an "unlisted procedure code" or an NOC code is indicated in item 24d, but an accompanying narrative is not presented in item 19 or on an attachment, the claim will be returned as unprocessable. This is a required field.

Item 24E

Enter the diagnosis code reference number as shown in Item 21 to relate to the date of service and the items or services rendered to the primary diagnosis. Enter only one reference number per line item. When multiple items or services are rendered, enter the primary reference letter for each service. This is a required field.

If a situation arises where two or more diagnoses are required for a procedure code, reference only one of the diagnoses in item 21.

Item 24G

Enter the number of days or units. If only one service is performed, the numeral 1 must be entered.

Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies). When multiple items or services are provided, enter the actual number provided.

NOTE: This field should contain at least one day or unit. The DME MAC will default to "1" unit when the information in this field is missing to avoid returning as unprocessable.

Item 24J

Enter your NPI number in the lower unshaded portion.

Item 25

Enter your Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. You are not required to complete this item for crossover purposes since the DME MAC will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim. However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed.

Item 27

Check the appropriate block to indicate whether you accept assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, you must also be a Medicare participating supplier and accept assignment of Medicare benefits for all covered charges for all patients. This box must be marked yes if you are a participating supplier, or if the claim is for drugs and biologicals.

Items 28, 29, 30

Item 28 - Enter total charges for the services (i.e., total of all charges in item 24f).

Item 29 - Enter the total amount the patient paid on the covered services only.

NOTE: This field may/will affect payment if assignment was accepted.

Item 30 - Leave blank. Not required by Medicare.

Item 31

Enter your signature (or that of your authorized representative) and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alphanumeric date (e.g., January 1, 1998) the form was signed.

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.

Items 32, 32a, 32b

Item 32 - If the services were furnished in a hospital, clinic, laboratory, or any facility other than the patient's home or physician's office, enter the name, address, and ZIP code of the facility. Only one name, address, and zip code may be entered in the block. If additional entries are needed, separate claim forms must be submitted.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States.

Item 32a - If required by Medicare claims processing policy, enter the NPI of the service facility.

Item 32b - Effective May 23, 2008, Item 32b is not to be reported.

Items 33, 33a, 33b

Item 33 - Enter your billing name, address, ZIP code, and telephone number. This is a required field.

Item 33a - Enter your NPI. This is a required field.

Item 33b - Effective May 23, 2008, Item 33b is not to be reported (unless billed via Indirect Payment Procedure (IPP); if you are an IPP biller, please follow IPP billing guidelines).