Form
Locator Requirement Field Description Guideline
1 Required Provider Name, Address, and Telephone Number Billing Provider Name, Address and Telephone Number: Enter the agency name, street, city, state, zip code, and telephone number. Line 1 – Provider Name Line 2 – Provider Street Address Line 3 – Provider City, State, Zip +4 Line 4 – Provider Telephone 4 Required Type of Bill Enter the three‐digit type of bill code. This field has been expanded from three to four characters with zero being the first digit. Claims will be processed based on the last three digits. 0831 (Special Facility – Ambulatory Surgery Center) 6 Required Statement Covers Period Enter the beginning and ending dates of service billed in
MMDDYY format.
8b Required Patient Name/Identifier
Enter the patient’s name as it appears on the Medical Assistance Card in last name, first name, middle initial format.
10 Required Patient Birth date Enter patient’s date of birth in MMDDYYYY format
11 Required Patient Sex
Indicate the patient’s gender M: Male
F: Female U: Unknown
12 Required Admission Date Enter the date the patient was admitted for care in
Form
Locator Requirement Field Description Guideline
43 Required if applicable Description Enter the 11‐digit National Drug Code (NDC) if billing for chemotherapy drugs 44 Required HCPCS/Rates/HIPPS Code Enter the appropriate CPT or HCPCS code relevant to the accommodation revenue code entered for the services being billed (see field 42 for more info). 46 Required Serv. Units Enter the total number of covered accommodation days or ancillary units of service for each revenue code billed as appropriate 47 Required Total Charges Enter the total charges for each related revenue/procedure code. Enter the grand total charges at the bottom of this field to be associated with revenue code 0001. 50 Required Payer Name As applicable, enter the name of the beneficiary’s primary, secondary, and tertiary insurance on lines A, B, and C. For claims with no TPL, DC Medicaid is entered on line A.
56 Required Billing Provider NPI Enter the National Provider Identifier for the billing
provider
58A‐C Required Insured’s Name
As applicable, enter the insured’s name for the primary, secondary and tertiary insurance on lines A, B, and C according to proper billing order. On the line that shows payer, Medicaid, enter the beneficiary’s name exactly as it appears on the Medical Assistance card.
59A‐C Required P. Rel
Enter the appropriate code indicating the relationship of the patient to the identified insured. 01: Spouse 18: Self 19: Child 20: Employee 21: Unknown 39: Organ Donor 40: Cadaver Donor 53: Life Partner G8: Other Relative
60A‐C Required Insured’s Unique ID
67 Required Principal Diagnosis Code
Enter the principal diagnosis code(s) provided at the time of admission as stated by the physician
69 Required Admit DX code Enter the diagnosis code provided at the time of
Form
Locator Requirement Field Description Guideline
022: Fiscal Agent Clm Process Error 088: Refund ‐ Provider Error 089: Refund‐ Fiscal Agent Error 088: Refund ‐ Provider Error 089: Refund‐ Fiscal Agent Error 088: Refund ‐ Provider Error 089: Refund‐ Fiscal Agent Error
81A ‐ D Required CC Enter the taxonomy code of the billing/pay‐to‐provider
preceded by the B3 qualifier.
