Assignment Claim Form Sample For A Private Case - Assignment Claim for Damages
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FAQ
Box 32b: If required by Medicare claims processing policy, enter the legacy Provider Identification Number (PIN) of the service facility preceded by the ID qualifier 1C. There should be one blank space between the qualifier and the PIN.
Box 17a is the non-NPI ID of the referring provider and is a unique identifier or a taxonomy code. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows: 2022 DN -- referring provider 2022 DK -- ordering provider 2022 DQ -- supervising provider 2022 Enter the qualifier to the left of the dotted vertical line on item 17.
Box 17 on the HCFA populates from information found in the Demographics tab, under Referring Doctor. The fields Referring Dr. First Name and Referring Dr. Last Name will be used, and the identifier DN will be applied.
Item 17a Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until , and MUST be reported if an NPI is not available.
