Claim Completion CMS 1500 Quick Guide

Prior Authorization Number: Enter the nine-digit Medicaid authorization number for services requiring authorization. Refer to the policy manual for specific requirements. Following are some of the services that require authorization:

• Elective inpatient services
• Out-of-state ambulance transports
• Select medical equipment and supplies
• Select prosthetic and orthotic services
• Select vision services
• Transplant services
• Other services as described in the provider policy manual or the Medicaid Databases. Clinical Laboratory Services:
Enter the CLIA number here when billing for clinical lab services. The CLIA number is a 10-digit number with "D" in the third position

Mandatory: Item is required …show more content…
3 Mandatory Enter the patient’s 8-digit birth date (MMDDCCYY) and sex.
4 Conditional, Mandatory if the patient has insurance primary to Medicaid.
6 Conditional, If item 4 is complete, check the appropriate box.
7 Conditional Complete if items 4 and 11 are completed.
9 Conditional, Mandatory if item 11d. is YES.
9a Conditional Enter second insurance policy or group number for policyholder in item 9.
9b Conditional Enter date of birth (MMDDCCYY) and sex for policyholder in item 9.
9c Conditional Enter employer or school name for policyholder in item 9.
9d Conditional Enter insurance plan name or program name for policyholder in item 9.
10a Mandatory Check YES or NO if condition is employment related.
10b Mandatory Check YES or NO if condition is related to an auto accident. If YES, indicate the state postal code.
10c Mandatory Check YES or NO if condition is related to accident other than auto.
11 Conditional Mandatory if patient has insurance primary to Medicaid. Enter primary insurance policy group number.
11a Conditional Enter the date of birth (MMDDCCYY) and sex for policyholder in item 4.
11b Conditional Enter the employer’s name or school for policyholder in item