Is to be attached to the top of each CMS1500 and must be completed in its entirety before submission of the claim. Inaccurate/Incomplete Cover Sheets will not be processed and will be returned for correction. 1. Medicaid Assigned Carrier Code enter the six- (6) digit carrier code assigned to the Medicare Advantage provider. All codes begin with H. and end with a trailing 0.(zero). 2. Medicare Paid Date enter the date of the Medicare Advantage Carrier Explanation of Benefits. 3. Medicai.
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How to fill out the Image Of Professional Instruction Sheet online
Completing the Image Of Professional Instruction Sheet is essential for submitting accurate Medicare Advantage claims. This guide provides simple, step-by-step instructions to ensure you fill out the form correctly and efficiently.
Follow the steps to successfully complete the Image Of Professional Instruction Sheet.
- Click ‘Get Form’ button to obtain the form and open it in the designated online editor.
- Enter the six-digit Medicaid Assigned Carrier Code. Ensure the code begins with an 'H' and ends with a trailing '0'.
- Input the Medicare Paid Date in the format MM-DD-YYYY, reflecting the date on the Medicare Advantage Carrier Explanation of Benefits.
- Fill in the seven-digit Medicaid Provider Number of the billing provider.
- Enter the thirteen-digit Recipient Identification Number. Ensure that you do not include the sixteen-digit Card Control Number.
- For Information for Line 1, enter the Medicare Allowed Amount for the charges. Additionally, complete the Total Deductible Amount and Total Co-Pay Amount only if they are separately identified on the Explanation of Benefits. Enter the Total Medicare Payment Amount for this line charge.
- Repeat the process for Lines 2-6, entering the requested Medicare Allowed Amount, Total Deductible Amount, and Total Co-Pay Amount as applicable.
- Once all sections are completed, review your entries to ensure accuracy before finalizing the document.
- Save changes, download, print, or share the completed form as needed.
Start filling out your Image Of Professional Instruction Sheet online today!
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