Kentucky Medicaid - Kymmis.com

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Required Information FIELD NUMBER NAME AND DESCRIPTION 10D Reserved for Local Use Enter the Physician Assistant’s NPI Number, if applicable. 11 Insured’s Policy Group or FECA Number Required only if member is covered by Commercial Insurance and ONLY if a payment is made, otherwise leave blank. 11C Insurance Plan Name or Program Name If an insurance company other than Medicaid has issued payment on a claim, enter the name of the other insurance company. Cabinet for Health and Family Services 8
Bottom Half of CMS Claim Form Cabinet for Health and Family Services 9
Page 1 and 2: Kentucky Medicaid Spring 2009 Billi
Page 3 and 4: Representative List Cabinet for Hea
Page 5 and 6: Reference List Helpful Phone Number
Page 7: Required Information FIELD NUMBER N
Page 11 and 12: Required Information FIELD NUMBER N
Page 13 and 14: Required Information FIELD NUMBER N
Page 15 and 16: Forms • Third Party Liability •
Page 17 and 18: TPL Helpful Hints • When to use t
Page 19 and 20: Adjustment, Claim Credit/Void Hints
Page 21 and 22: Cash Refund Hints The Cash Refund D
Page 23 and 24: Timely Filing Examples 1 Year From
Page 25 and 26: Timely Filing Examples KyHealth Net
Page 27 and 28: FAQ’s If you bill Medicare and d
Page 29 and 30: FAQ’S Cont. Internal Control Num
Page 31 and 32: Did You Know * Coming Soon--Paper
Page 33: KY MMIS Project Provider Evaluation

Kentucky Medicaid - Kymmis.com

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