Web22. RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE From To B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPSCS MODIFIER E. DIAGNOSIS POINTER (A-L) F. $ CHARGES G. DAYS OR … WebCMS-1500 Claim Form; Box 1 - Plan Type; Box 1a - Insured's I.D. Number; Box 2 - Patient's Name; Box 3 - Patient's Birth Date, Sex; Box 4 - Insured's Name; Box 5 - Patient's Address (multiple fields) Box 6 - Patient Relationship to Insured; Box 7 - Insured's Address (multiple fields) Box 8 - Reserved for NUCC Use; See more

CHCP - Resources - Electronic Claims Submission - Cigna

WebCMS-1500 should be submitted with the appropriate resubmission code (value of 7) in Box 22 of the paper claim with the original claim number of the corrected claim. Include a … WebDec 21, 2013 · When billing Medicaid, billers need to fill in Box 22 of the HCFA CMS 1500 Claim Form when they need to show proof of timely filing on a resubmission of a claim … eye specialist warners bay

Claim investigation and corrected claim submission procedures …

WebJul 24, 2024 · Box 22 is used to list the Original Reference Number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate … http://www.nucc.org/images/stories/PDF/1500_form_map_to_837p_4010a1_v1-0_112008.pdf Web(On the UB04, this is the third position in the Type of Bill Box or on the CMS 1500, it is Box 22 - Resubmission Code) Use one of these codes: 1 – Original (admit through … does bath fitters finance