Effective May 23, 2008 all claims submitted to MHP must contain the National Provider
Identifier (NPI) required in FL 24 J of the CMS-1500 form and FL 56 of the UB 04 form.
Please click on the link below to view detail instructions on each field locator of the new
CMS-1500 (02-12) version and UB-04 paper claims format. Please access the details by
clicking on the following links to review the tables to identify the fields that are mandatory,
conditional, and/or blank.
Effective October, 13 2013
CMS1500 (02-12) Submission Guidelines
UB-04 submission guidelines
Guidelines for submitting- CMS-1500(02-12) Claims Form
Item
Status
Description
Insured’s ID Number as shown on insured’s ID card
Enter the patient’s last name, first name, and middle initial (if
any) in that order
Enter the patient’s 8 – digit birthrate (MMDDCCYY) and sex
Mandatory if the patient’s has other insurance primary to
Medicaid
Enter patient’s current address on file
If item 4 is complete check the appropriate box, Patient
relationship to Insured
Complete if item 4 and 11 are completed
Reserve for NUCC use only
Mandatory if item 11d. is YES
Enter second insurance policy or group number for policyholder
in item 9
Reserve for NUCC use only
Reserve for NUCC use only
Enter insurance plan name or program name for policyholder in
item 9
Check YES or NO if condition is employment related
Check YES or NO if condition is related to an auto accident. If
YES, indicate the state postal code
Check YES or NO if condition is related to accident other than
auto
CLAIM CODES (Designated by NUCC).
Mandatory if patient has insurance primary to Medicaid. Enter
primary insurance policy group number
Enter date of birth (MMDDCCYY) and sex for policyholder in
item 4
1a
2
Mandatory
Mandatory
3
4
Mandatory
Conditional
5
6
Mandatory
Conditional
7
8
9
9a
Conditional
Conditional
Conditional
Conditional
9b
9c
9d
Conditional
Conditional
Conditional
10a
10b
Mandatory
Mandatory
10c
Mandatory
10d
11
Conditional
Conditional
11a
Conditional
11b
11c
Conditional OTHER CLAIM ID (Designated by NUCC).
Conditional Enter insurance plan name or program name for policyholder in
Revised 7/1/13
11d
14
17
17a,b
18
19
21
item 4
If yes , complete items 9, 9a, and 9d
If item 10b or 10c is Yes, date of accident must be reported
Enter the referring/ordering physician’s name as required
Enter the 10
-digit Medicaid provider ID# of the provider in item 17, if
available
Conditional Report the admit & discharge dates for services during an
inpatient hospital stay
Conditional ADDITIONAL CLAIM INFORMATION (Designated by
NUCC)
Mandatory Enter the ICD_9_CM or ICD 10 diagnosis code(s) 1 thru 12 to the highest
Conditional
Conditional
Conditional
Conditional
level of specificity (e.g., using the 4t, 5th digit or alphanumeric categories
A-L) that describes the patient's condition
22
Conditional
Resubmission code 7 and Original Form #
23
Conditional
Enter the Midwest prior authorization number for services requiring
an authorization or the ten-digit CLIA number as appropriate. Click
on link to see the authorization requirements Authorization and
Referral Procedures
Enter the 8 – digit (MMDDCCYY) ‘from’ and ‘to’ date for each
service
24B,C Mandatory
Enter the appropriate 2 – digit place of service code
Old single digit codes will not be accepted
Emergency Indicator Y=yes, N=no
24D
Mandatory
Procedures, Services, or Supplies (CPT or HCPCS), Modifier
24E
Mandatory
Diagnosis Pointer
24F
Mandatory
Enter your charge without decimals, commas, or dollar signs
24G
Mandatory
Enter the number of units
24I
Mandatory
Qualifying Id if other than NPI
24J
Mandatory
Rendering Provider ID# shaded area for non NPI #’s, non-shaded
area NPI required
25
Mandatory
Enter the provider’s Federal Tax ID or Social Security Number
26
Mandatory
Enter the patient account number assigned by the provider or
supplier
28
Mandatory
Enter sum of charges in 24F
29
Conditional Report amount of other insurance payment
30
Conditional Rsvd for NUCC Use
31
Mandatory
Signature of provider or supplier and date
32
Mandatory
Enter name and address of facility where services were rendered
and NPI# of the facility
Billing Provider’s or Supplier’s name, address, zip code and phone
33A,B Mandatory
number. (A)Billing provider’s NPI
24A
Mandatory
Revised 7/1/13