part ii policies and procedures for rural health clinic services

Completion of the Health Insurance Claim Form (CMS-1500) (Items not required byGeorgia DMA are not included in these instructions)This section provides specific instructions for completing the Health Insurance Claim Form(CMS-1500) [12-90]. A sample invoice is included for your reference.Item 1Item 1aItem 2Item 3Health Insurance CoverageCheck Medicaid box for the patient‟s coverage.Insured‟s I.D. NumberEnter the Member Medicaid Number exactly as it appears on the member‟scurrent Card.Patient‟s NameEnter the Patient‟s name exactly as it appears on the Eligibility Card (last namefirst).Patient‟s Date of Birth and SexEnter the patient‟s 8-digit birth date (MM/DD/CCYY) and sex.Item 9Other Insured‟s NameIf the member has other third party coverage for these services, complete with thename of the policyholder. If no other third party coverage is involved, leave blank.Medicare is not considered third party.A reasonable effort must be made to collect all benefits from other third partycoverage. Federal regulations require that Medicaid be the payer of last resort.(See Chapter 300 of the Policies and Procedures Manual applicable to allproviders.)When a liable third party carrier is identified within the computer system, theservices billed to Medicaid will be denied. The information necessary to bill thethird party carrier will be provided as part of the Remittance Advice on the ThirdParty Carrier Page.Item 9aItem 9dItem 10January 2012Other Insured‟s Policy or Group NumberIf the member has other third party coverage for these services, enter the policy orgroup number.Insurance Plan Name or Program NameEnter the insurance plan name or the program name and carrier code. (*Carriercodes are located in the Third Party Insurance Carrier Listing.)Was Condition Related ToCheck all the appropriate boxes.Rural Health Clinic Services E-5