part ii policies and procedures for rural health clinic services

FL 54 Prior PaymentsA, B, C Enter the amount that the hospital has received toward payment of this bill fromthe carrier.FL 58Insured‟s NameEnter the insured‟s last name, first name, and middle initial. Name mustcorrespond with the name on the Medicaid card. If the name on the Medicaid cardis incorrect, the member or the member‟s representative should contact the localDFCS to have it corrected immediately.FL 60 Certification/SSN/HIC/ID No.A, B, C Enter the Medicaid Member Client Number exactly as it appears on the Medicaidcard.FL 61 Insured Group NameA, B, C Enter the name of the group or plan through which the insurance is provided tothe insured. Medicaid requires the primary payer information on their primarypayer line when Medicaid is secondary.FL 62 Insurance Group NumbersA, B, C Enter the identification number, control number, or code assigned by the carrier oradministrator to identify the group under which the individual is covered.FL 63 Treatment Authorization Code (Precertification)A, B, C A number or other indicator that designates that the treatment covered by this billhas been authorized by the DMA. Enter the twelve-digit authorization number asrequired for inpatient hospital admissions and selected outpatient procedures, ifapplicable.FL 63 Employment Status CodeA, B, C Enter the code as defined by the National Uniform Billing Committee used todefine the employment status of the individual identified in FL 58.FL 65 Employer NameA, B, C Enter employer name that might or does provide health care coverage for theindividual in FL 58.FL 66 Employer LocationA, B, C Enter the specific location of employer of the insured individual identified in FL58.FL 67Principle Diagnosis CodeEnter the ICD-9-CM code for the principal diagnosis appearing in FL 76.January 2012 Rural Health Clinic Services E-14