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HCFA 1500 Filing Instructions | UB-92 Filing Instructions | C-19 Filing Instructions
ADA Filing Instructions
Bills should be submitted to the MCO is a timely manner, preferably within 30 days of treatment date. Although not ideal, bills may be submitted as late as 2 years after the date of service or 6 months from the date of determination.
To be considered for payment, bills must be submitted on BWC approved forms. The approved forms include the ADA form, HCFA 1500, UB-92, and C-19. More information about each of these forms can be found in the BWC´s Billing and Reimbursement Manual. (To obtain of copy of this manual, contact the BWC at (800)OHIOBWC) or on the web at www.ohiobwc.com.
No additional information needs to accompany the bill unless specifically directed to do so on a case by case basis. Additional documentation (such as medical documentation, C9s, etc.) should be sent or forwarded separately to the appropriate department within the MCO.
- Indicate the BWC Claim Number on the Bill.
- Submit Bills According to BWC format.
- Use the BWC Issued 11 digit Servicing Provider Number in Box 25 of the HCFA 1500 Form or Box 11 on the C-19 Form.
- Use the BWC Issued 11 digit Group or Pat to Provider Number in Box 33 of the HCFA 1500 Form or Box 14 of the C-19 Form.
- Indicate Diagnosis Code on All Line Items of the Bill Regardless of the Provider Type.
- Indicate Two-Digit Place of Service Code.
- Submit Bills with the First Report of Injury (FROI)
- Balance Bill the Injured Worker or Ask for Co-Payment
- Unbundle Services
Bills may be submitted:
Via U.S. Mail, Via Email, Via fax, Via EDI (After May 1, 2001)
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HCFA 1500 Filing Instructions
The following line by line instructions for completing the HCFA 1500 are provided in the BWC´s Billing and Reimbursement Manual.
- TYPE OF HEALTH CARE COVERAGE:
- INSURED´S ID NO.: Enter the BWC claim number
- PATIENT´S NAME: Enter claimant´s last name, first name, and middle initial
- PATIENT´S DATE OF BIRTH AND SEX: Enter the claimant´s date of birth in m-dd-yy format. (For example, use 8-21-39 for Aug. 21, 1939). Use an "X" to mark the appropriate gender box.
- INSURED´S NAME: Enter employer´s name on self-insured bills.
- PATIENT ADDRESS: Enter the claimant´s full mailing address, including street number, P.O. Box, or rural route number, city, state, and zip code.
- PATIENT´S RELATIONSHIP TO INSURED:
- INSURED´S ADDRESS:
- PATIENT STATUS:
- OTHER INSURED´S NAME:
- OTHER INSURED´S POLICY OR GROUP NUMBER:
- OTHER INSURED´S DATE OF BIRTH:
- EMPLOYER´S NAME OR SCHOOL NAME:
- INSURANCE PLAN NAME OR PROGRAM NAME:
- IS PATIENT´S CONDITION RELATED TO:
- INSURED´S POLICY GROUP OR FECA NUMBER: Enter the social security number of the claimant. Required on self-insured bills only.
- INSURED´S DATE OF BIRTH:
- EMPLOYER´S NAME OR SCHOOL NAME:
- INSURANCE PLAN NAME OR PROGRAM NAME:
- IS THERE ANOTHER HEALTH BENEFIT PLAN?:
- PATIENT´S OR AUTHORIZED PERSON´S SIGNATURE:
- INSURED´S OR AUTHORIZED PERSON´S SIGNATURED:
- DATE OF CURRENT INJURY: Enter the date of injury
- IF PATIENT HAS HAD SOME SIMILAR ILLNESS. GIVE FIRST DATE: Enter the date of injury or illness
- DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION: Use BWC form C-84 to document patient´s dates of disability
- NAME OF REFERRING PHYSICIAN OR OTHER SOURCE: Required only for consultation codes 99241-99263. Enter the referring physician´s full name or BWC provider number (17a)
- HOSPITALIZATION DATES RELATED TO CURRENT SERVICES:
- RESERVED FOR LOCAL USE:
- OUTSIDE LAB:
- DIAGNOSIS OR NATURE OF ILLNESS OR INJURY: Leave blank. A diagnosis code must be entered in block 24E for each procedure billed
- MEDICAID RESUMBISSION:
- Prior Authorization Number: (Leave Blank)
- LINE DETAIL:
- DATE(S) OF SERVICE: Enter the beginning date of service (from date) in m/d/yy BWC will not accept any medical bill that contains more than one date of service per line item. Line items which contain a different "From" and "To" date will be denied with the following EOB 269: "Payment is denied as BWC allows only one date of service per line item."
- PLAN OF SERVICE: BWC has adopted the HCFA two digit place of service indicators. Effective 1/1/99 line items on medical bills processed without a valid BWC place of service code will be denied.
| 11 – Office |
26 – Military Treatment Facility |
51 – Psychiatric Facility, Inpatient |
62 – Comprehensive Rehab Facility |
| 12 – Home |
31 – Skilled Nursing Facility |
52 – Psychiatric Facility, Partial Hospitalization |
65 – End Stage Renal Disease Treatment Facility |
| 21 – Hospital Inpatient |
32 – Nursing Facility |
53 – Community Mental Health Center |
71 – State or Local Public Health Clinic |
| 22 – Hospital Outpatient |
33 – Custodial Care Facility |
54 – Intermediate Care Facility/Mentally Retarded |
72 – Rural Health Clinic |
23 – Hospital Emergency Department |
34 – Hospice |
55 – Residential Substance Abuse Treatment Facility |
81 – Independent Laboratory |
24 – Ambulatory Surgical Center |
41 – Ambulance, Land |
56 – Psychiatric Residential Treatment Center |
99 – Other Unlisted Facility |
25 – Birthing Center |
42 – Ambulance, Air or Water |
61 – Comprehensive Inpatient Rehab Facility |
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- TYPE OF SERVICE: No entry required
- PROCEDURES, SERVICES, OR SUPPLIES: Enter the following information as it applies to each part of the field:
- CODE: Enter the five-digit CPT or other HCPCS code
- MODIFIER: When applicable, enter the 2 digit modifier code. These codes more fully describe the services performed, so that accurate payment can be determined
- DIAGNOSIS CODE: Enter the ICD-9-CM code that corresponds to the primary diagnosis. Enter only one code per line. This is the primary condition you are treating. Services should be related to the diagnosis billed. NOTE: Enter the diagnosis code exactly as it appears in the ICD-9-CM code book. The use of "V" and "E" diagnosis codes will result in the denial of the bill.
- $ CHARGES: Enter your usual, customary, and reasonable charge for the procedure performed. If more than one unit of service is billed, make sure your charges reflect this in the total.
- DAYS OR UNITS: Enter the units of service rendered for each detail line. A unit of service is the number of times a procedure is performed. When only one procedure is performed, a "1" must appear in this field
- EPSDT FAMILY PLAN:
- EMG:
- COB:
- RESERVED FOR LOCAL USE:
- FEDERAL TAX I.D. NUMBER:
- Group Providers: Enter the 11-digit BWC provider number of the individual treating practitioner.
- Individual Providers: Enter the 11-digit BWC provider number of the individual treating practitioner.
- PATIENT´S ACCOUNT NO: Enter the claimant´s patient account number. Any letter of number combination up to 15 characters is acceptable. This item is optional. NOTE: If you enter a patient account number in this field, it will appear on the BWC Remittance Advice
- ACCEPT ASSIGNMENT:
- TOTAL CHARGE: Add all charges in column 24f and enter the total amount in this block.
- AMOUNT PAID:
- BALANCE DUE: Enter the same figure as block 28
- SIGNATURE OF PHYSICIAN SUPPLIER INCLUDING DEGREES OR CREDENTIALS: An authorized or handwritten signature must appear in this block.
- NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED(IF OTHER THAN HOME OR OFFICE): Enter the name and address where the services were provided, if different from block 33.
- PHYSICIAN´S, SUPPLIER´S BILLING NAME, ADDRESS, ZIP CODE, & PHONE #: Enter name, address, and telephone number to whom payment is to be made in the lower right hand block under GRP#. If blank, the bill will be returned. Tax information will be reported for the provider number entered in this block to the IRS.
PIN#: Leave blank
GRP#: See below:
A. Enter the 11 digit BWC provider number of the group practice to whom the payment is to be made
B. Enter the 11 digit BWC provider number of the individual provider to whom the payment is to be made
Completion of blocks 25 and 33 correctly is imperative for accurate processing and reimbursement of your bills. Failure to identify the individual treating provider or individual physician´s provider number in block 25 will result in denial of your bill.
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UB-92 Filing Instructions
The following line by line instructions for completing the UB-92 are provided in Chapter 18 of the BWC´s Billing and Reimbursement Manual.
- UNTITLED: Enter the hospital´s name and address. Entering the hospital´s telephone number is optional
- UNTITLED:
- PATIENT CONTROL NUMBER: This item is optional. Enter the injured worker´s unique patient account number. Any combination up to 17 alphanumeric characters is acceptable. NOTE: If you enter a patient control number in this field, it will appear on the remittance advice from BWC
- TYPE OF BILL: Enter the appropriate 3 digit code for the type of bill from the coding table below:
| 111 – Admit-discharge date |
131 – Admit through discharge date |
| 112 – Interim first bill |
132 – Interim first bill |
| 113 – Interim continuing bill |
133 – Interim continuing bill |
| 114 – Interim last claim |
134 – Interim last claim |
| 115 – Late charges only |
135 – Late charges only |
*Type of bill codes 115 and 135 are only acceptable in hard copy bill submissions. Type of bill codes 116-118, and 136-138 for adjustments, replacements and voids of prior bills are not valid for BWC. Requests for adjustments should be directed to your provider representative.
- FEDERAL TAX ID NUMBER:
- STATEMENT COVERS PERIOD: (Required) Enter the beginning and ending service dates for this bill in month, day, year format. IMPORTANT: Surgery dates and accompanying operating room charges must be within the date span listed in the "statement covers" period. For outpatient bills, the first and last of the line item service dates entered in item 45 must be equivalent to the first and last dates in the statement covers period.
- COVERED DAYS: No entry required
- NON-COVERED DAYS:
- CO-INSURANCE DAYS:
- LIFETIME RESERVE DAYS:
- UNTITLED:
- PATIENT NAME: Enter the injured worker´s last name, first name, and middle initial
- PATIENT ADDRESS: Enter the injured worker´s address or P.O. Box number, city, state and zip code
- PATIENT BIRTH DATE: Enter the injured worker´s date of birth in a month, day, and year format
- PATIENT SEX: Enter the injured worker´s gender
- PATIENT MARITAL STATUS: No entry required
- ADMISSION DATE: (Required) Enter the injured worker´s date of admission in month, day, year format
- ADMISSION HOUR: (Required) Enter the hour of admission converted into 24 hour time
- TYPE OF ADMISSION: Enter the code number indicating the type of admission
Emergency 1
Urgent 2
Elective 3
Transfer 7
Rehabilitation 8
- SOURCE OF ADMISSION: Enter the code indicating the source for the admission
| 1 – Physician referral |
4 – Transfer from a hospital |
7 – Emergency room |
| 2 – Clinic referral |
5 – Transfer from a skilled nursing facility |
8 – Court/law enforcement |
| 3 – HMO referral |
6 – Transfer from another health care facility |
9 – Information not available |
- DISCHARGE HOUR: Enter the hour the injured worker was discharged converted into 24 hour time. Not required for outpatient visits.
- PATIENT STATUS: Enter the code indicating the patient status as of the "statement covers" period date
01 – Discharged to home/self care (routine)
02 – Discharged/transferred to another short term general hospital
03 – Discharged/transferred to skilled nursing facility (SNF)
04 – Discharged/transferred to intermediate care facility (ICF)
05 – Discharged/transferred to another type of institution for inpatient or outpatient services
06 – Discharged/transferred to home under care of organized home health service organization
07 – Left against medical advice or discontinued care
20 – Expired
30 – Still a patient
- MEDICAL RECORD NUMBER: Enter the injured worker´s unique medical record number assigned by the provider, for BWC and the self-insured employer to note when requesting medical record information
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- CONDITION CODES: Enter a condition code used to identify conditions relating to this bill, if applicable
- UNTITLED:
- OCCURRENCE CODES AND DATES: Enter the code and associated date defining a significant event relating to this bill. If only one code and date are used, they must be entered in item 32. If more than one code and date are used, they must be entered in items 32 through 35. Enter the date in month, day, and year format.
- OCCURRENCE CODES AND DATES: Enter the code and associated date defining a significant event relating to this bill. If only one code and date are used, they must be entered in item 32. If more than one code and date are used, they must be entered in items 32 through 35. Enter the date in month, day, and year format.
- OCCURRENCE CODES AND DATES: Enter the code and associated date defining a significant event relating to this bill. If only one code and date are used, they must be entered in item 32. If more than one code and date are used, they must be entered in items 32 through 35. Enter the date in month, day, and year format.
- OCCURRENCE CODES AND DATES: Enter the code and associated date defining a significant event relating to this bill. If only one code and date are used, they must be entered in item 32. If more than one code and date are used, they must be entered in items 32 through 35. Enter the date in month, day, and year format.
- OCCURRENCE SPAN CODE AND DATES:
- INTERNAL CONTROL NUMBER/DOCUMENT CONTROL NUMBER/TRANSACTION CONTROL NUMBER:
- RESPONSIBLE PARTY NAME AND ADDRESS:
- VALUE CODES AND AMOUNTS: Enter the value code and its related dollar amount that identifies data of monetary nature, if applicable
- VALUE CODES AND AMOUNTS: Enter the value code and its related dollar amount that identifies data of monetary nature, if applicable
- VALUE CODES AND AMOUNTS: Enter the value code and its related dollar amount that identifies data of monetary nature, if applicable
- REVENUE CODE: Enter the appropriate 3 digit revenue center code itemizing all accommodation and ancillary charges. Revenue codes 960-989 may not be billed on this invoice.
- REVENUE DESCRIPTION:
- HCPCS/RATES:
Enter the accommodation rate for accommodation codes
Enter the CPT or HCPCS codes applicable to outpatient services.
- SERVICE DATE: For outpatient bills only, enter the date the indicated outpatient service was provided, in month, day, year format
- UNITS OF SERVICE: Enter the number of days for accommodations. For all other revenue center codes, enter the units of service. Late discharge should not be billed as an additional day.
- TOTAL CHARGES: Enter the total charge for each BWC covered and non-covered revenue code or procedure code entry. Ohio payers will only accept 21 lines of revenue data per one page bill. BWC requires that line 22 be left blank, and line 23 be title "Total" and used to record the total of box 47. NOTE: The total in line 23 of box 47 is the total of all BWC covered and non-covered charges. BWC reimburses only for covered services
- NON-COVERED CHARGES: No entry required
- UNTITLED FIELD:
- PAYER: Enter BWC, MCO, or the name of the self-insuring employer
- PROVIDER NUMBER: Enter the 11 digit BWC provider number. IMPORTANT: The dash in the provider number should not be included.
- RELEASE OF INFORMATION, CERTIFICATION INDICATOR:
- ASSIGNMENT OF BENEFITS, CERTIFICATION INDICATOR:
- PRIOR PAYMENTS:
- ESTIMATED AMOUNT DUE:
- UNTITLED FIELD:
- UNTITLED FIELD:
- INSURED´S NAME:
- PATIENT´S RELATIONSHIP TO THE INSURED:
- CERTIFICATE/SOCIAL SECURITY NUMBER/HEALTH INSURANCE CLAIM/IDENTIFICATION NUMBER: Enter the injured worker´s social security number.
- INSURED´S GROUP NAME: (a-c)
- INSURED´S GROUP NUMBER: Enter the BWC claim number (a-c)
- TREATMENT AUTHORIZATION: For inpatient bills only, enter the authorization which covers this hospitalization. Authorization requests must be approved prior to the inpatient admission or by the first business day after the admission. NOTE: Inpatient bills will not be reimbursed if prior authorization was not received.
- EMPLOYMENT STATUS CODE:
- EMPLOYER NAME: Enter the name of the employer
- EMPLOYER LOCATION: Enter the location of the employer
- PRINCIPAL DIAGNOSIS CODE: Enter the ICD-9-CM diagnosis code describing the principal diagnosis. NOTE: Omission of the principal diagnosis allowed in the claim will result in denial of the bill. Effective 8/1/96 BWC will accept "V" codes for the principal diagnosis on inpatient bills only, not outpatient bills. BWC cannot accept "E" codes for the principal diagnosis.
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- OTHER DIAGNOSIS CODES (OTHER THAN PRINCIPAL): Enter the ICD-9-CM diagnosis code(s) corresponding to additional conditions that coexist at the time of the admission or develop subsequently and which have an effect on the treatment received or the length of stay. NOTE: "V" or "E" codes are acceptable for the "other diagnosis codes".
- ADMITTING DIAGNOSIS CODE: Enter the ICD-9-CM diagnosis code provided at the time of admission or as stated by the physician. NOTE: "V" or "E" codes are acceptable
- EXTERNAL CAUSE OF INJURY CODE (E CODE):
- UNTITLED FIELD:
- PROCEDURE CODE METHOD USED:
- PRINCIPAL PROCEDURE CODE AND DATE: Enter the code identifying the principal ICD-9-CM surgical procedure performed during the period and covered by this bill, and the date on which the principal procedure was performed. Enter the date in month, day, year format.
- OTHER PROCEDURE CODES AND DATES: Enter the codes and dates identifying the procedures other then the principal procedures.
- ATTENDING PHYSICIAN´S IDENTIFICATION: Enter the BWC provider number for the attending physician
- OTHER PHYSICIAN´S IDENTIFICATION: If a consultant is involved, enter the BWC (a-b) provider number(s) for the consultant(s)
- REMARKS:
- PROVIDER REPRESENTATIVE SIGNATURE: Enter an authorized signature
- DATE BILL SUBMITTED: Enter the date on which the bill was submitted in month, day, year format.
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C-19 Filing Instructions
The following line by line instructions for completing the C-19 Service Invoice are provided in Chapter 18 of the BWC´s Billing and Reimbursement Manual.
- UNTITLED ´ TYPE OF BILL: Check the appropriate bill type:
| "K" |
"N" |
"P" |
"V" |
"R" |
Dental |
Nursing Home Services |
Practitioner |
Ambulance |
Rehab Provider |
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Therapist |
Vision |
Traumatic Brain Injury |
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Anesthesia |
Orthotics & Prosthetics |
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Chronic Pain Program |
DME |
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Ambulatory Surgical Ctr |
Home Health Agency |
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Unlicensed Caregiver |
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- CLAIM NUMBER: Enter the BWC claim number
- CLAIMANT SOCIAL SECURITY NUMBER: Enter the claimant´s social security number. Required on self-insured bills
- DATE OF INJURY: Enter the date of injury. Use the month, day, year format.
- CLAIMANT NAME: Enter the claimant´s last name, first name, and middle initial
- CLAIMANT ADDRESS: Enter the claimant´s full mailing address including street number, P.O. Box number, or rural route number, city, state, and zip code
- REFERRING PHYSICIAN PROVIDER NUMBER: Required only for consultation codes. If known, enter the referring physician´s BWC provider number. Otherwise, enter the full name in item 8.
- REFERRING PHYSICIAN´S NAME: Required only for consultation codes
- PRIOR AUTHORIZATION NUMBER: Enter the authorization number if prior authorization is required for these services
- PATIENT ACCOUNT NUMBER: Enter the claimant´s patient account number. Any letter or number combination up to 15 characters is acceptable. This item is optional. NOTE: If you enter a patient account number, it will appear on the remittance advice.
- PROVIDER NUMBER:
Enter the BWC provider number of the treating practitioner
Individual Providers: Enter the 11 digit assigned BWC provider number and skip items 12 & 14
- PROVIDER NAME:
Enter the provider name that corresponds to the provider number listed in item 11
- CHECK HERE IF PAYMENT IS TO BE MADE TO THE CLAIMANT: Check this block if the payment should go to the claimant.
- GROUP PAYEE NUMBER:
Enter the BWC provider number to which payment is to be made. Item 11 must contain the treating practitioner´s provider number.
- SERVICE DATE: Enter the date service was rendered in the month, day, year format. If the same procedure is provided on consecutive days, enter the beginning and ending dates
- PLACE OF TREATMENT: Enter the place of service code for each procedure performed from the list under 24B of the line-by-line billing instructions for the HCFA-1500
- PROCEDURE CODE (CPT): Enter the appropriate CPT or other HCPCS code for the service rendered
- MODIFICATION CODE: For certain types of service, a 2 digit modifier must be entered after the procedure code. Modifiers describe more completely the services performed so that accurate payment may be determined.
- DIAGNOSTIC CODE (ICD-9-CM): Enter the ICD-9-CM code that corresponds to the primary diagnosis. Enter only one code per line. This is the primary condition you are treating.
Enter the diagnosis code exactly as it appears in the ICD-9-CM code book. Use the most specific diagnosis code from the ICD-9-CM code book. If there is a fourth and/or fifth digit, it is a required part of the code.
Each line must contain a diagnosis. DO NOT use ditto marks in this field.
- DESCRIPTION OF SERVICE: Enter the description of the procedure code. Abbreviations of the description of service are acceptable.
- CHARGES: Enter your usual, customary, and reasonable charge for the procedure performed. If more than one unit of service is billed, make sure that you compensate for this in your charges.
- UNITS OF SERVICE: Enter the units of service rendered for each detail line. A unit of service is the number of times a procedure is performed. NOTE: When only one procedure is performed, a "1" must appear in this field. When the same procedure is performed on consecutive days, enter the number of days and enter a beginning and an ending date in item 15.
- TOOTH NUMBER: Enter the tooth number(s) if applicable.
- PROVIDER SIGNATURE: Enter an authorized signature
- DATE: Enter the date the bill was signed. Use the month, day, year format
- TOTAL CHARGE: Add together all charges in Column 21 and enter the total amount in this field.
- REMARKS: Enter employer´s name on self-insured bills.
- PAYEE NAME, ADDRESS, CITY, STATE, ZIP CODE, AND TELEPHONE NUMBER: Enter the name, address, zip, and telephone number of provider to whom payment is to be made
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ADA Filing Instructions
The following line by line instructions for completing the American Dental Association (ADA) Form are provided in Chapter 18 of the BWC´s Billing and Reimbursement Manual.
- Use this field to enter the authorization number, if the services require prior authorization
- CARRIER NAME AND ADDRESS: Enter the name and address of either BWC, the MCO, or the self-insured employer
- PATIENT NAME: Enter the claimant´s full name
- RELATIONSHIP TO EMPLOYEE:
- SEX: Check the appropriate box to indicate the claimant´s sex
- PATIENT BIRTHDATE: Enter the patient´s birth date in month, day, and year format (i.e. 08/21/55 for Aug. 21, 1955)
- IF FULL TIME STUDENT:
- EMPLOYEE/SUBSCRIBER NAME AND MAILING ADDRESS: Enter the claimant´s address
- EMPLOYEE/SUBSCRIBER DENTAL PLAN ID NUMBER: Enter the claimant´s social security number
- EMPLOYEE/SUBSCRIBER BIRTHDATE:
- EMPLOYER (COMPANY) NAME AND ADDRESS:
- GROUP NUMBER: Enter the BWC claim number
- IS PATIENT COVERED BY ANOTHER PLAN OF BENEFITS:
- a. NAME AND ADDRESS OF CARRIER(S): This field is used to enter the patient account number. Any letter or number combination up to 15 characters is acceptable.
b. GROUP NUMBER:
- NAME AND ADDRESS OF EMPLOYER: Enter employer´s name for self insuring bills
- a. EMPLOYEE/SUBSCRIBER NAME:
b. EMPLOYEE/SUBSCRIBER DENTAL PLAN ID NUMBER:
c. EMPLOYEE/SUBSCRIBER BIRTHDATE:
- RELATIONSHIP TO PATIENT:
PATIENT SIGNATURE:
INSURED PERSON´S SIGNATURE:
- PATIENT SIGNATURE:
- EMPLOYEE/SUBSCRIBER SIGNATURE:
- NAME OF BILLING DENTIST OR DENTAL ENTITY: Enter the name of the provider to whom payment is to be made
- ADDRESS WHERE PAYMENT SHOULD BE REMITTED: Enter the address of the provider where payment is to me mailed
- CITY, STATE, ZIP: Enter the city, state, zip of the provider where payment is to be mailed
- DENTIST´S SOCIAL SECURITY NUMBER OR T.I.N.: Enter the 11 digit BWC assigned provider number. If the payee is a group practice, enter the treating dentist´s 11 digit BWC provider number.
- DENTIST´S LICENSE NUMBER: If payment is to be made to a group practice, enter the 11 digit BWC assigned group provider number. If payment is to be made to an individual, leave blank.
- DENTIST´S PHONE NUMBER: Enter the office telephone number including the area code.
- FIRST VISIT, DATE CURRENT SERIES:
- PLACE OF TREATMENT: Enter the place of service code for each procedure performed from the list under 24B of the line-by ´line billing instructions of the HCFA-1500
- RADIOGRAPHS OR MODELS ENCLOSED?
- IS TREATMENT RESULT OF OCCUPATIONAL ILLNESS OR INJURY? Enter the date of injury in the space to the right of the "yes" box
- IS TREATMENT RESULT OF AUTO ACCIDENT?
- OTHER ACCIDENT?
- IF PROSTHESIS, IS THIS INITIAL PLACEMENT?
- DATE OF PRIOR PLACEMENT:
- IS TREATMENT FOR ORTHODONTICS?
- IDENTIFY MISSING TEETH WITH "X": Identify the missing teeth, if any
- EXAMINATION AND TREATMENT PLAN: Enter the field required for each of the services performed from the list below:
1 – Tooth number or letter
2 – Description of service
3 – Date service performed
4 – Procedure number (use ADA codes)
5 – Fee (usual, customary, and reasonable)
M.D./Dentists must use the HCFA-1500 or the BWC Service Invoice C-19 for CPT codes
- REMARKS FOR UNUSUAL SERVICES:
- SIGNATURE/DATE LINE: Enter an authorized signature and the date the invoice was signed
- ADDRESS WHERE TREATMENT WAS PERFORMED: Enter the address where treatment was performed
- TOTAL FEE CHARGED: Enter the total fee charged for all services listed in block #37
- PAYMENT BY OTHER PLAN:
Concentra MPN
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