part ii policies and procedures for rural health clinic services

Item l0aItem l0bItem 10cItem 14Item 17Item 17aItem 20Item 21Employment? (Current or Previous)Check the appropriate box.Auto Accident?Check the appropriate box.Other Accident?Check the appropriate box.Date of Current Illness. Injury or PregnancyEnter the exact or approximate date of either the first symptom of illness; injury oraccident; or last menstrual period (in the case of pregnancy).Name of Referring PhysicianEnter the name of the physician or other source who referred the patient. Leaveblank if there is no referral.ID Number of Referring PhysicianEnter the referring physician UPIN (Unique Physician Identification Number) orMedicaid provider number or State license number. Item 18Hospitalization Dates Related to Current ServicesEnter the dates of admission and discharge from an inpatient facility in month,date, year, (MM/ DD/YY) format.Outside LaboratoryCheck Yes or No. Charges are not needed.Diagnosis or Nature of Illness or InjuryEnter the ICD-9-CM diagnosis code related to the service billed on the line. Thespecial categories of codes which begin with ”E” and “M” are not acceptable bythe Division. The remaining special categories of codes which begin with “V” areacceptable only when the code describes the primary diagnosis and indicatessuspected or proven conditions which warrant medically necessary services.When coding any diagnosis on the claim, the code must appear on the claim formusing the identical format (excluding the decimal point) as shown in the ICD-9-CM book (example: 2943).Item 22 Medicaid Resubmission TCN #Enter the TCN (Transaction Control Number) of the previous denied claim youare resubmitting.Item 23January 2012Prior Authorization NumberEnter the twelve digit Precertification Number as required for inpatient hospitaladmissions and selected outpatient hospital or ambulatory surgical center servicesas issued by the Georgia Medical Care Foundation, if applicable,Rural Health Clinic Services E-6