part ii policies and procedures for rural health clinic services

Item 24fItem 24gChargesEnter in the bottom unshaded portion the product of your “usual and customary”charge for the procedure multiplied times the units of service.Days or UnitsEnter in the bottom unshaded portion the number of times the procedure wasperformed. Units billed should be evenly divisible by the number of days in Item24a.NOTE:If you are billing more than one (1) unit for the same procedure code on the same date of service,please use one (1) line on the CMS-1500 and in field G list your total units. If you use more thanone line, the system will consider the subsequent lines a duplicate and will deny them.Item 24hEPSDT/Family PlanningIf the services were provided as a result of a referral by the Health Check(EPSDT) Program, enter “ET”. The Health Check program is only for individualsunder twenty-one years of age.OrIf this service was for family planning purposes, enter “FP”. Please consult yourPolicies and Procedures manual for further information on which procedures arerelated to family planning.This field is required for all Health Check/Family Planning procedures codesbilled on claim. If neither applies, leave blank.Item 26Item 28Item 29Rev 01/09Item 30Item 31Patient‟s Account No.Enter the patient‟s record number used internally by the clinic. If not used, leaveblank.Total ChargeEnter the total of the charges listed for each line.Amount PaidEnter the amount received from third party. If not applicable, leave blank.Note: Do not enter Medicaid co-payments collected at the time of service into thisfield. Do not enter Medicare payment information in this field.Balance DueEnter the submitted charge less any third party payment received.Signature of Physician or Supplier Including Degrees or CredentialsThe provider must sign or signature stamp each claim for services rendered andJanuary 2012Rural Health Clinic Services E-8