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INTRODUCTION

CMS-1500 Instructions

The following table identifies the fields that are required and provides a description of the field.

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FORM FIELD

REQUIRED

DESCRIPTION

Element 01-Program Block/Claim Sort Indicator

YES

Element 01a–Insured's I.D. Number

YES

All claims require one of the following recipient numbers in order for processing. Enter the recipient's Alien Identification Number. If not available, enter recipient's Fingerprint ID Number. If not available, enter recipient's Event Number. Do not enter any other numbers or letters. It is the referring custodial facility's responsibility to provide this information to the provider.

Element 02 – Patient's Name

YES

Enter the recipient's last name, first name, and middle initial.

Element 03 – Patient's Birth Date, Patient's Sex

YES

Enter the recipient's birth date in MM/DD/YY format (e.g., February 3, 1955, would be 02/03/55) or in MM/DD/YYYY format (e.g., February 3, 1955, would be 02/03/1955). Specify whether the recipient is male or female by placing an “X” in the appropriate box.

Element 04 – Insured's Name

YES

Element 05 – Patient's Address

YES

Enter the detention facility's address where the recipient resides. If recipient in custody of Border Patrol, enter the Border Patrol Station of the Border Patrol Officer(s). Do not use the detainee's home address.

Element 06 - Patient Relationship to Insured

Element 07 – Insured's Address

YES

Enter the detention facility's address where the recipient resides. If recipient in custody of Border Patrol, enter the Border Patrol Station of the custodial Border Patrol Officers.

Element 08 - Patient Status

Element 09 -Other Insured's Name

Element 10 - Is Patient's Condition Related to

YES

Element 11 – Insured's Policy, Group, or FECA Number

YES

FORM FIELD

REQUIRED

DESCRIPTION

Element 11a – Insured's Date of Birth and Sex

YES

Element 11b - Employer's Name or School Name

Element 11c - Insurance Plan Name or Program Name

YES

Enter “Immigration Health Services.”

Elements 12 and 13 - Authorized Person's Signature

YES

Element 14 -Date of Current Illness, Injury, or Pregnancy

Element 15 - If Patient Has Had Same or Similar Illness

Element 16 -Dates Patient Unable to Work in Current Occupation (not required)

Elements 17 and 17a - Name and I.D. Number of Referring Physician or Other Source

YES WHEN APPLICABLE

Element 18 -Hospitalization Dates Related to Current Services

YES WHEN APPLICABLE

Element 19 - Reserved for Local Use

Element 20 -Outside Lab?

Element 21 -Diagnosis or Nature of Illness or Injury

YES

Enter the most current International Classification of Diseases, Clinical Modification (ICD-9-CM) diagnosis code for each symptom or condition related to the services provided. List the primary diagnosis first.

Element 22 - Medicaid Resubmission

Element 23 - Prior Authorization Number

YES

Enter the Authorization # for service. All Claims require an Authorization # for processing. It is the referring custodial facility's responsibility to provide this information to the provider.

Element 24A - Date(s) of Service

YES

Enter the ...

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