Web75.1 - Form Locators 1-15 (Rev. 1929, Issued: 03-09-10; Effective Date: 07-01-10; Implementation Date: 07-06-10) Form Locator (FL) 1 - Billing Provider Name, Address, and Telephone Number Required. The minimum entry is the provider name, city, State, and ZIP Code. The post office box number or street name and number may be included. WebForm Locator Name Form Locator Code Notes 12 Admission Date LB Do not complete this Form Locator. 13 Admission Hour LB Do not complete this Form Locator. 14 Admission Type M Enter 1 for an emergency treatment – the condition requires immediate medical attention and any time delay would be harmful to the patient.
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WebForm Locator 57 (Provider No.) – Form Locator 57a must contain the Medicare HMO provider number, while Form Locator 57b will contain the 13-digit Medical Assistance provider number, when MA is secondary to an MA HMO. If MA is tertiary to a Medicare HMO, complete Form Locators 57a, 57b, and 57c accordingly, denoting the primary in … WebApr 1, 2024 · Beginning April 1, 2024, paper CMS 1500 claim submissions that include a date within fields 14 and 15 must also include an appropriate Qualifier value (as noted in the table in below) to identify the date being reported. taylor ebony cutting board
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Webappropriately in Form Locator 9a-e. 9a = Street address 9b = City: 9c = State 9d = Zip Code 9e = Zip Plus Formerly entered in UB-92 Form Locator 13. 10 Patient's Birthdate … WebJan 22, 2024 · Form Locator 14: Type of visit: 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available. Form Locator 15: Point of origin (source of admission). Form Locator 16: Discharge hour in the same format as line 13. Form Locator 17 Discharge Status: use the two-digit codes from the NUBC manual. WebForm Locator 14 — Admission Type (not required) Form Locator 15 — Admission Src (not required) Form Locator 16 — DHR (not required) Form Locator 17 — Stat (not … taylore baker baseball coach