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  • Non-direct Billing Claim Form - Part A Patient Information

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NonDirect Billing Claim Form Part A Patient Information A For a claim to be valid, the following two pages (Part A and B) must be completed and submitted to MSH CHINA ENTERPRISE SERVICES CO., LTD.

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Item 24D - Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 claim form has the capacity to capture up to four modifiers.

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Box 23 is used to show the payer assigned number authorizing the service(s).

BLOCK 24 List only one servicing provider on each CMS 1500 claim form. Use a separate line for each service provided. If more than six services were provided for a recipient, a separate claim form for the seventh and any additional services must be completed.

A Place of Service (POS) is a field used when completing a CMS 1500 form to submit a claim to insurance. It indicates the location in which the health care service is actually provided.

Note: Claims for Physical, Occupational and Speech Therapy billed on a CMS 1500 form should include the rendering provider's National Provider ID (NPI). The rendering provider's NPI, and taxonomy, if applicable, should be entered in box 24J on the CMS 1500. This will ensure proper processing and payment for services.

9. Name of the INSURED PERSON of other payer in Insurance Information screen under Patient Master.

A Place of Service (POS) is a field used when completing a CMS 1500 form to submit a claim to insurance. It indicates the location in which the health care service is actually provided.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232