Medicare Assured® HMO

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Claims and Billing
Claims
Billing
Claims
General Information
Procedures for Gateway are as follows:
- Payment for CPT and HCPCS codes are covered to the extent that they are HIPAA compliant. Gateway utilizes CMS place of service codes to process claims, and they are the only place of service codes that are accepted.
- Hospitals should bill on an original UB-04 Form, and other providers, including ancillary providers should bill using an original CMS-1500 (08-05) Form.
- Gateway does accept bills through electronic data interchange (EDI) and encourages facilities and providers to submit claims via this format.
- Electronic claims must include NPI provider number and may continue to include the Gateway ID Number (Legacy Number) as a secondary identifier. Correct/current practitioner information identified as the Gateway Provider ID Number (Legacy Number) must be entered on all paper claims. Gateway Provider ID numbers are 5 or 7 digits. EDI claims submitted without an NPI will be rejected.
- Correct/current member information, including Gateway Health Plan Medicare Assured® HMO Member ID Number, must be entered on all claims. The format is 8 or 12 digits for the Gateway member number. Gateway member number or HIC number in alpha and numeric format will be accepted on Electronic claims. Gateway prefers that the Gateway ID number be submitted to assure that the claim is processed under the correct individual.
- Please allow four to six weeks for a remittance advice. It is the practitioner’s responsibility to research the status of a claim.
- Gateway encourages providers to submit initial bills within 180 days from the date of service, however any initial claim not submitted within 180 days must be submitted within 365 days from the date of service. Initial bills submitted after 365 days will be denied as untimely.
- Corrected claims or requests for review are considered if information is received within the 120-day follow-up period from the date on the remittance advice.
- Gateway is secondary to any commercial plan. Claims must be submitted within Gateway’s timely filing guidelines.
- For other than inpatient hospital confinements paid as Part A, Gateway pays the lesser of the billed amount or the allowable amount.
- Inpatient hospital claims must be submitted with an MS-DRG Code.
- Providers of obstetric services are reimbursed on a global basis for deliveries. Individual visits are not reimbursed and should not be billed.
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Timely Filing
Practitioners are encouraged to submit a complete original, initial CMS-1500 (08-05) or UB-04 Form within 180 calendar days after the date of service. If you bill on paper Gateway will only accept paper claims on a CMS-1500 (08-05), or a UB-04 Form. No other billing forms will be accepted.
Practitioners must bill within 365 calendar days from the date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary. An original bill along with a copy of the EOB is required to process the claim. Requests for reviews/corrections of processed claims must be submitted within 120 calendar days from the date of the corresponding remittance advice. All claims submitted after the 365-day period following receipt of the EOB or after the 120-day follow-up period from the date on the remittance will be denied.
Any claim that has been submitted to Gateway but does not appear on a remittance advice within 60 days following submission should be researched by the practitioner. Call Gateway’s Provider Services Department to inquire whether the claim was received and/or processed.
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Electronic Claims Submission
Gateway can accept claims electronically through Emdeon or RelayHealth. Gateway encourages practitioners to take advantage of our electronic claims processing capabilities. Submitting claims electronically offers the following benefits:
- Faster Claims Submission and Processing
- Reduced Paperwork
- Increased Claims Accuracy
- Time and Cost Savings
For submission of professional or institutional electronic claims for Gateway Health Plan Medicare Assured® HMO, please refer to the following grid for Emdeon Payer IDs and RelayHealth CPIDs(Clearinghouse Process ID):
| CPID |
PAYER NAME |
PAYER ID |
CLAIM TYPE |
| 2298 |
Gateway Health Plan® - PA Medicare Assured® HMO |
60550 |
Professional |
| 2912 |
Gateway Health Plan® - PA Medicare Assured® HMO |
60550 |
Institutional |
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Requirements for Submitting Claims to Gateway Through Emdeon and RelayHealth
To submit claims to Gateway Health Plan Medicare Assured® HMO please note the Pennsylvania Payer ID Number is 60550. Gateway has a health plan specific edit through Emdeon and RelayHealth for electronic claims that differ from the standard electronic submission format criteria. The edit requires:
- A Gateway assigned 8-digit member identification number, the member number field allows 6, 8, or 12 digits to be entered. For practitioners who do not know the member’s Gateway identification number it is acceptable to submit the member’s HIC Number on electronic claims.
In addition to edits that may be received from Emdeon and RelayHealth, Gateway has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted to Emdeon and RelayHealth, but if the codes are not currently valid they will be rejected by Gateway. Practitioners must be diligent in reviewing all acceptance/rejection reports to identify claims that may not have successfully been accepted by Emdeon, RelayHealth and Gateway. Edits applied when claims are received by Gateway will appear on an EDI Report within the initial acceptance report or Claims Acknowledgment Report. A claim can be rejected if it does not include an NPI and current procedure and diagnosis codes. To ensure that claims have been accepted via EDI, practitioners should receive and review the following reports on a daily basis:
- Emdeon -- Provider Daily Statistics (RO22)
- Emdeon -- Daily Acceptance Report by Provider (RO26)
- Emdeon -- Unprocessed Claim Report (RO59)
- RelayHealth – Claims Acknowledgment Report (CPI 651.01)
- RelayHealth – Exclusion Report (CPI 652.01)
- RelayHealth – Claims Status Report (CPA 425.02)
If you are not submitting claims electronically, please contact your EDI vendor for information on how you can submit claims electronically. You may also call Emdeon directly at 1-877-469-3263 or RelayHealth at 1-800-545-2488.
Gateway will accept electronic claims for services that would be submitted on a standard CMS-1500 (08-05) or a UB-04 Form. However, the following cannot be submitted as attachments along with electronic claims at this time:
- Claims with EOBs
- Services billed by report
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Claims Review Process
Gateway will review any claim that a practitioner feels was denied or paid incorrectly. The request may be conveyed in writing (per instructions below), or verbally through Gateway’s Provider Services Department if the inquiry relates to an administrative issue. Please forward hard copy information via mail to the Claims Review Department along with all of the appropriate documentation, i.e. the actual claim, medical records, and notations regarding telephone conversations, in order to expedite the review process. Initial claims that are not received within the timely filing limit will not qualify for review. All follow-up review requests must be received within 120 calendar days of the initial remittance advice.
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Administrative Claims Review
Claims that need to be reviewed based upon administrative or processing issues are handled by a Provider Services Representative via a phone call to Gateway. For inquiries requiring documentation or received in the mail, Claims Review Representatives evaluate whether the documentation attached to the claim is sufficient to allow it to be reconsidered. Claims that qualify for adjustments will be reprocessed, and claim information will appear on subsequent remittance advices. Claims that do not qualify for reconsideration will be forwarded to the Appeals Department for review. All review requests must be received within 120 days of the initial remittance advice.
Please refer to the Appeals and Grievances Section of the manual for information on procedures for Appeals submitted by providers on behalf of a member.
Claims inquiries for administrative reviews should be mailed to: Gateway Health Plan®, Attention: Claims Review Department, US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219-2704.
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Coordination of Benefits
Some Gateway Health Plan Medicare Assured® HMO members have other insurance coverage. Gateway follows Medicare coordination of benefits rules. Gateway does not deny or delay approval of otherwise covered treatment or services unless the probable existence of third party liability is identified in Gateway’s records for the member at the time the claims are submitted.
Please note the following criteria applies and designates when Gateway is not the primary plan for Medicare covered members:
- Enrollee is 65+ years, and covered by an Employer Group Health Plan (EGHP) because of either current employment or current employment of a spouse of any age and the employer employs 20 or more employees.
- Enrollee is disabled, and covered by an Employer Group Health Plan because of either current employment or a family member’s current employment, and the employer that sponsors or contributes to the Large EGHP plan employs 100 or more employees.
- For an enrollee entitled to Medicare solely on the basis of end-stage renal disease and Employer Group Health Plan coverage (including a retirement plan), the first 30 months of eligibility or entitlement to Medicare.
- Workers’ compensation settlement proceeds are available.
- No-fault or liability settlement proceeds are available.
In order to receive payment for services provided to members with other insurance coverage, the practitioner must first bill the member’s primary insurance carrier using the standard procedures required by the carrier. Upon receipt of the primary insurance carrier’s Explanation of Benefits, the practitioner should submit a claim to Gateway. The practitioner must:
- Follow all Gateway authorization and billing procedures.
- File all claims within timely filing limits as required by the primary insurance carrier.
- Submit a copy of the primary carrier’s EOB with the claim to Gateway within 365 days of the date of the primary carrier’s EOB.
- The amount billed to Gateway must match the amount billed to the primary carrier. Gateway will coordinate benefits; the provider should not attempt to do this prior to submitting claims.
Members seeking care, regardless of primary insurer, are required to contact their primary care practitioner and use participating practitioners or obtain appropriate authorization for practitioners outside of the network.
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Claim Coding Software
Gateway uses a fully automated coding review product that programmatically evaluates claim payments to verify the clinical accuracy of processing claims in accordance with clinical editing criteria. This coding program contains complete sets of rules that correspond to CPT-4, HCPCS, ICD-9, AMA, and CMS guidelines as well as industry standards, medical policy and literature and academic affiliations. CCI (Correct Coding Initiative) edits are applied solely to Incidental and Mutually Exclusive outcomes while the coding software applies other editing criteria. The program used at Gateway is designed to ensure data integrity for ongoing data analysis and reviews procedures across dates of service and across providers at the claim level.
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Provider Payment Dispute Resolution for Non-Contracted Gateway Health Plan Medicare Assured® HMO Providers
If you are a non-contracted provider and you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.
To file a payment dispute with Gateway Health Plan®, call us at 800-685-5205 or send a written dispute to:
Gateway Health Plan®
Attn: Claims Department, Gateway Medicare Assured® HMO
NON-PAR PAYMENT DISPUTE
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Additionally, please provide appropriate documentation to support your payment dispute e.g., a remittance advice from a Medicare carrier. Claims must be disputed within 120 days from the date payment is initially received by the provider.
We will review your dispute and respond to you within 30 days from the time the provider payment dispute is first received by the plan. If we agree with your payment dispute, then we will pay you the additional amount with any interest that is due. We will inform you in writing if your payment dispute is denied.
After Gateway Health Plan Medicare Assured® HMO makes it’s final Payment Review Determination Decision and you still disagree with the pricing decision, a request for an independent Payment Dispute Decision (PDD) may be submitted to “First Coast Services, Inc“, an independent entity contracted by CMS, in writing within 180 days of written notice from Gateway Health Plan Medicare Assured® HMO Payment Review Determination. For more information and forms on PDD can be obtained at (www.fcso.com, What We Do, Payment Dispute Resolutions – Medicare Advantage).
First Coast Service Options, Inc (FCSO)
Payment Dispute
P.O. Box 4017
Jacksonville, Florida 32231-4017
Fax: 904-361-0551
Email: RDPC@fcso.com
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Billing
Billing Procedures
A “clean claim” as used in this section means a claim that has no defect, impropriety, lack of any required substantiating documentation, including the substantiating documentation needed to meet the requirements for encounter data, or particular circumstance requiring special treatment that prevents timely payment; and a claim that otherwise conforms to the clean claim requirement for equivalent claims under Medicare.
In addition, a claim shall be considered “clean” if the appropriate authorization has been obtained in compliance with Gateway’s Policy and Procedure Manual and the following elements of information are furnished on a standard UB-04 or CMS-1500 (08-05) Form (or their replacement with CMS designations, as applicable) or an acceptable electronic format through a Gateway-contracted clearinghouse:
- Patient name;
- Patient medical plan identifier;
- Date of service for each covered service;
- Description of covered services rendered using valid coding and abbreviated description;
- ICD-9 surgical diagnosis code(s) (as applicable);
- Name of practitioner/provider and applicable NPI number;
- Provider tax identification number;
- Valid CMS place of service code(s);
- Billed charge amount for each covered service;
- Primary carrier EOB when patient has other insurance;
- All applicable ICD-9-CM diagnosis codes—inpatient claims include diagnoses at the time of discharge or in the case of emergency room claims, the presenting ICD-9-CM diagnosis code;
- MS-DRG code for inpatient hospital claims.
Gateway processes medical expenses upon receipt of a correctly completed CMS-1500 (08-05) Form and hospital expenses upon receipt of a correctly completed UB-04. Sample copies of a UB-04 and a CMS-1500 (08-05) Form can be found in the Forms and Reference Material Section of this manual. A description of each of the required fields for each form is identified later in this section. Paper claim forms must be submitted on original forms printed with red ink.
A claim without valid, legible information in all mandatory categories is subject to rejection/denial. To ensure reimbursement to the correct payee, the correct NPI number must be included on every claim. If the NPI number submitted for the provider does not match the vendor (payee) in Gateway’s records, Gateway will issue payment to the correct vendor assigned to the provider based on the tax identification number received on the claim.
To comply with processing requirements, primary care practitioners and specialty care practitioner must submit claims under the individual practitioner NPI number rather than the practice or group identification number. Submissions for anesthesiology, pathology, radiology, and emergency room practitioner groups must also include the individual practitioner NPI number. Any claim billed on a CMS-1500 (08-05) Form must include the individual practitioner NPI in box 33 on the form. Please note that it is extremely important to promptly notify Gateway of any change that involves adding practitioners to any group practice, as failure to do so may result in a denial of service.
All claims must have complete and accurate ICD-9-CM diagnosis codes for claims consideration. If the diagnosis code requires, but does not include the fourth or fifth digit classification, the claim will be denied.
Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. By signing a claim for services, the practitioner certifies that the services shown on the claim were medically indicated and necessary for the health of the patient and were personally furnished by the practitioner or an employee under the practitioner’s direction. The practitioner certifies that the information contained in the claim is true, accurate and complete.
Gateway’s claim office address for Pennsylvania is: Gateway Health Plan Medicare Assured® HMO, Claims Processing Department, P.O. Box 11-560, Albany, NY 12211-0560.
Any questions concerning billing procedures or claim payments can be directed to Gateway’s Provider Services Department at 1-800-685-5205.
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Family Planning Services
Gateway Health Plan Medicare Assured® HMO members are eligible for all of the benefits covered under the Medicare Program. All prospective and current Gateway Health Plan Medicare Assured® HMO members receive information about specific counseling and referral services that are normally part of the Medicare benefit package, but for which Gateway cannot directly provide due to objections based on moral or religious grounds. Gateway has made alternate arrangements for Medicare covered counseling or referral services related to contraceptive services, female sterilization services, male sterilization services and abortion services. Gateway Health Plan Medicare Assured® HMO members may self-refer to a participating Medicare provider for these services. All family planning services, as noted above, for Gateway Health Plan Medicare Assured® HMO members are paid using an alternate process.
For practitioners and facilities, family planning services are defined as all Medicare covered evaluation, diagnostic or surgical services provided with a diagnosis code in series V25, or V26.1, V26.22, V26.51, V26.52, V26.8, V26.9 and by the CPT codes listed below related to contraception and abortion services. (Follow Medicare guidelines for submission of sterilization services.)
| Contraceptive Services |
Abortion Services |
| 11976 – Removable implantable contraceptive capsule |
59840 - Induced abortion by dilation and curettage |
| 58301 – Removal of IUD |
59841 - Induced abortion by dilation and evacuation |
| |
59850 - Induced abortion by one or more intra-amniotic injections |
| |
59851 - Induced abortion by one or more intra-amniotic injections with D&C or evac |
| |
59852 - Induced abortion...with hysterotomy |
| |
59855 - Induced abortion by one or more vaginal suppositories |
| |
59856 - Induced abortion...with D&C or evac |
| |
59857 - Induced abortion...with hysterotomy |
| |
59866 - Multifetal pregnancy reduction |
All CPT codes related to abortions must be billed with the "G7" modifier. Providers must complete the Medicare abortion certification forms and retain in their medical records. A copy of the certification form is NOT required with your claim submission.
CPT codes shall be implemented and updated in accordance with the release and implementation of updates by the Center for Medicare and Medicaid Services.
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Surgical Procedure Services
Gateway determines reimbursement of surgical procedures upon the clinical intensity of each procedure and reimburses at 100% for the most clinically intensive surgery, and 50% for the subsequent procedures. Reimbursement for more than 5 procedures requires medical record documentation. Pre- and post-operative visits will only be reimbursed to the extent that they qualify for payment according to the follow-up criteria.
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Hospital Services
Hospital claims are submitted to Gateway on a UB-04. To assure that claims are processed for the correct member, the member’s 8-digit Gateway identification number must be used on all claims. To aid in the recording of payment, patient account numbers recorded on the claim form by the practitioner are indicated in the Patient ID field on the Gateway remittance advice. Please review field numbers below carefully as many of them differ from the former UB-92 format.
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UB-04 Data Elements for Submission of Paper Claims Forms
EDI requirements must be followed for Electronic claims submissions
| Field |
Description |
Requirements |
| 1 |
Provider Name, Address, City, State, Zip, Telephone, Fax, Country Code |
Required |
| 2 |
Pay to Name, Address, City, State, Zip |
Required If Different from Billing Provider in Field 1 |
| 3a |
Patient Control Number |
Required |
| 3b |
Medical Record Number |
Not Required |
| 4 |
Type of Bill |
Required - If 4 Digits Submitted, the Lead 0 will be Ignored |
| 5 |
Federal Tax Number |
Required |
| 6 |
Statement Covers Period |
Required |
| 7 |
Unlabeled Field |
Not Used |
| 8a |
Patient Name |
Required |
| 9 |
Patient Address |
Required |
| 10 |
Birthdate |
Required |
| 11 |
Patient Sex |
Required |
| 12 |
Admission Date |
Required for Inpatient and Home Health |
| 13 |
Admission Hour |
Not Required |
| 14 |
Type of Admission/Visit |
Required, If Inpatient |
| 15 |
Source or Admission |
Required |
| 16 |
Discharge Hour |
Not Required |
| 17 |
Patient Status |
Required |
| 18-28 |
Condition Codes |
May be Required in Specific Circumstances (Consult CMS Criteria) |
| 29 |
Accident State |
Not Used |
| 30 |
Unlabeled Field |
Not Used |
| 31-34 |
Occurrence Codes and Dates |
May be Required in Specific Circumstances (Consult CMS Criteria) |
| 35-36 |
Occurrence Span Codes and Dates |
Required, If Inpatient |
| 37 |
Unlabeled Field |
Not Used |
| 38 |
Responsible Party Name and Address |
Not Required |
| 39-41 |
Value Codes and Amounts |
Required, If Inpatient |
| 42 |
Revenue Codes |
Required |
| 43 |
Revenue Descriptions |
Required |
| 44 |
HCPCS/Rates/HIPPS Codes |
Required, If Outpatient |
| 45 |
Service Dates |
Required, If Outpatient |
| 46 |
Service Units |
Required |
| 47 |
Total Charges |
Required |
| 48 |
Non-covered Charges |
Required, If Applicable |
| 49 |
Unlabeled Field |
Not Used |
| 50 |
Payer Identification |
Required |
| 51 |
Health Plan ID |
Not Required |
| 52 |
Release of Information Certification Indicator |
Required |
| 53 |
Assignment of Benefits |
Not Used |
| 54 |
Prior Payments |
Required, If Applicable |
| 55 |
Estimated Amount Due from Patient |
Not Required |
| 56 |
National Provider ID |
Required - NPI Number |
| 57 |
Other Provider ID |
Gateway Health Plan® Practitioner Identification Number should be entered on paper claims only- legacy number reported as secondary identifier to NPI on electronic claims |
| 58 |
Insured's Name |
Required, If Applicable |
| 59 |
Patient Relationship to Insured |
Required, If Applicable |
| 60 |
Certificate-Social Security Number-Health Insurance Claim-Identification Number |
Gateway Member Identification Number Required |
| 61 |
Insurance Group Name |
Required, If Applicable |
| 62 |
Insurance Group Number |
Required, If Applicable |
| 63 |
Treatment Authorization Code |
Required, If Applicable |
| 64 |
Document Control Number |
Not Required |
| 65 |
Employer Name |
Required, If Applicable |
| 66 |
Diagnosis and Procedure Code Qualifier |
Required |
| 67 |
Principal Diagnosis Code |
Required (Coding for Present on Admission data required) |
| 67A-67Q |
Other Diagnosis Code |
Required (Coding for Present on Admission data required) |
| 68 |
Unlabeled Field |
Not Used |
| 69 |
Admitting Diagnosis Code |
Required |
| 70A-70C |
Patient Reason for Visit |
Not Required |
| 71 |
Prospective Payment System (PPS) Code |
Required for DRG Code – If 4 Digits Submitted, the Lead 0 will be Ignored |
| 72 |
External Cause of Injury Codes |
Not Used |
| 73 |
Unlabeled Field |
Not Used |
| 74 |
Principal Procedure Code and Date |
Required, If Applicable |
| 74A-74E |
Other Procedure Codes and Date |
Required, If Applicable |
| 75 |
Unlabeled Field |
Not Used |
| 76 |
Attending Provider Name and Identifiers (Including NPI) |
May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send |
| 77 |
Operating Provider Name and Identifiers (Including NPI) |
May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send |
| 78-79 |
Other Provider Name and Identifiers (Including NPI) |
May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send |
| 80 |
Remarks |
May be Required in Specific Circumstances (Consult CMS Criteria) |
| 81 |
Code – Code Field |
Optional (Consult CMS Criteria) |
CMS-1500 (08-05) Data Elements for Submission of Paper Claims Forms
| Field # |
Description |
Requirements |
| 1 |
Insurance Type |
Required |
| 1a |
Insured Identification Number |
Gateway Health Plan® Member Identification Number |
| 2 |
Patient's Name |
Required |
| 3 |
Patient's Birth Date |
Required |
| 4 |
Insured's Name |
Required |
| 5 |
Patient's Address |
Required |
| 6 |
Patient Relationship to Insured |
Required |
| 7 |
Insured's Address |
Required |
| 8 |
Patient Status |
Required |
| 9 |
Other Insured's Name |
Required, If Applicable |
| 9a |
Other Insured's Policy or Group Number |
Required, If Applicable |
| 9b |
Other Insured's Date of Birth, Sex |
Required, If Applicable |
| 9c |
Employer's Name or School Name |
Required, If Applicable |
| 9d |
Insurance Plan Name or Program Name |
Required, If Applicable |
| 10 |
Is Patient Condition Related to:
a. Employment
b. Auto accident
c. Other accident |
Required, If Applicable |
| 10d |
Reserved for Local Use |
Not Required |
| 11 |
Insured's Policy Group or FECA Number |
Required |
| 11a |
Insured's Date of Birth, Sex |
Required, If Applicable |
| 11b |
Employer's Name or School Name |
Required, If Applicable |
| 11c |
Insurance Plan Name or Program Name |
Required, If Applicable |
| 11d |
Is There Another Health Benefit Plan? |
Required, If Applicable |
| 12 |
Patient or Authorized Person's Signature |
Required |
| 13 |
Insured's or Authorized Person's Signature |
Required |
| 14 |
Date of Current: Illness OR Injury OR Pregnancy |
Required, If Applicable |
| 15 |
If Patient has had Same or Similar Illness, Give First Date |
Not Required |
| 16 |
Dates Patient Unable to Work in Current Occupation |
Required, If Applicable |
| 17 |
Name of Referring Practitioner or Other Source |
Required |
| 17a,b |
Identification Number of Referring Practitioner |
|
| 18 |
Hospitalization Dates Related to Current Services |
Required, If Applicable |
| 19 |
Reserved for Local Use |
May be Required in Specific Circumstances (Consult CMS Criteria) |
| 20 |
Outside Lab |
Not Required |
| 21 |
Diagnosis or Nature of Illness or Injury |
Required |
| 22 |
Medical Resubmission Code |
Not Required |
| 23 |
Prior Authorization Number |
Not Required |
| 24a |
Date(s) of Service |
Required |
| 24b |
Place of Service |
Required |
| 24c |
Type of Service |
Not Required |
| 24d |
Procedures, Services, or Supplies CPT/HCPCS/Modifier |
Required |
| 24e |
Diagnosis Code |
Required |
| 24f |
Charges |
Required |
| 24g |
Days or Units |
Required |
| 24h |
EPSDT Family Plan |
Not Required |
| 24i |
ID Qualifier |
Required, if applicable |
| 24j |
Rendering Provider ID |
Not Required |
| 25 |
Federal Tax Identification Number |
Required |
| 26 |
Patient Account Number |
Not Required |
| 27 |
Accept Assignment |
Not Required |
| 28 |
Total Charge |
Required |
| 29 |
Amount Paid |
Not Required |
| 30 |
Balance Due |
Not Required |
| 31 |
Signature of Practitioner or Supplier including degrees or credentials |
Gateway Individual Practitioner Name and Date Required |
| 32 |
Service Facility Location Information |
Facility Name and Address where Services were Rendered Required |
| 33 |
Billing Provider Info and Phone # |
Gateway Vendor (Payee) Name, Address, and Phone Number Required. NPI and Gateway Legacy Number should be Entered. |
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