Instructions for "Waiver/Rehab Claim Form" - Rhode Island

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Waiver Services – Waiver/Rehab Claim Form Instructions
FIELD NAME
INSTRUCTIONS
Recipient Number
Enter the recipient’s Medicaid identification
number
Patient Name
Enter 5 characters of the last and 2
characters of the first name of the recipient
who received services from the provider
Primary Diagnosis
Enter the diagnosis code for the primary
illness or injury for which the recipient was
treated. Select an ICD-9 or ICD-10 diagnosis
code depending on date of service.
Secondary Diagnosis
Enter the diagnosis code for the secondary
illness or injury (if any) for which the
recipient was treated. Select an ICD-9 or
ICD-10 diagnosis code depending on date of
service. If none, leave blank.
Procedure Code
Enter the five character HCPCS code that
describes the procedure performed.
Modifiers
Enter up to three modifiers that apply to the
HCPCS procedure code in Box #5.
Level of Care (LOC)
Leave blank.
Patient Liability
Enter the amount the patient must pay for
each procedure.
From Date
Enter the beginning month, day or year of
the service being billed.
Thru Date
Enter the last date (day) of the service billed.
OI Indicator
Enter “Y” if the service being billed is covered
by any other insurance, including Medicare.
Enter “N” if it is not.
OI Code
Enter the three digit carrier code of the other
insurance.
OI Amount
Enter the dollar amount that all other
insurance carriers have paid toward the
services rendered on this claim line.
Units
Enter the number of units billed for the
service on each claim line.
Rate
Enter the amount charged per unit of service
on each claim line.
Charge
Enter the total amount charged for the
service on each claim line (rate times units)
PR0076 V1.1 8/19/15
Waiver Services – Waiver/Rehab Claim Form Instructions
FIELD NAME
INSTRUCTIONS
Recipient Number
Enter the recipient’s Medicaid identification
number
Patient Name
Enter 5 characters of the last and 2
characters of the first name of the recipient
who received services from the provider
Primary Diagnosis
Enter the diagnosis code for the primary
illness or injury for which the recipient was
treated. Select an ICD-9 or ICD-10 diagnosis
code depending on date of service.
Secondary Diagnosis
Enter the diagnosis code for the secondary
illness or injury (if any) for which the
recipient was treated. Select an ICD-9 or
ICD-10 diagnosis code depending on date of
service. If none, leave blank.
Procedure Code
Enter the five character HCPCS code that
describes the procedure performed.
Modifiers
Enter up to three modifiers that apply to the
HCPCS procedure code in Box #5.
Level of Care (LOC)
Leave blank.
Patient Liability
Enter the amount the patient must pay for
each procedure.
From Date
Enter the beginning month, day or year of
the service being billed.
Thru Date
Enter the last date (day) of the service billed.
OI Indicator
Enter “Y” if the service being billed is covered
by any other insurance, including Medicare.
Enter “N” if it is not.
OI Code
Enter the three digit carrier code of the other
insurance.
OI Amount
Enter the dollar amount that all other
insurance carriers have paid toward the
services rendered on this claim line.
Units
Enter the number of units billed for the
service on each claim line.
Rate
Enter the amount charged per unit of service
on each claim line.
Charge
Enter the total amount charged for the
service on each claim line (rate times units)
PR0076 V1.1 8/19/15
Total OI
Enter the total amount paid by all other
insurance listed (in column 15) on all claim
lines.
Total Charge
Enter the total amount of all the charges
listed (in column 16) on all the claim lines.
Billing Provider Number
Enter the NPI of the provider submitting the
claim. Be sure this information is on the
correct line or claim will not process.
Billing Provider Name
Enter the name of the provider submitting
the claim. Be sure this information is on the
correct line or claim will not process.
Billing Provider Taxonomy
Enter the billing provider taxonomy. Be sure
this information is on the correct line or claim
will not process.
Performing Provider Number
Enter the NPI of the provider who performed
the service.
Performing Provider Name
Enter the first and last names of the provider
who actually performed the service. (Leave
blank if the same as field #1)
Performing Provider Taxonomy
Enter the taxonomy for the provider who
performed the service.
ICD-IND
Enter 9 for ICD-9 diagnosis codes and 0 for
ICD-10 diagnosis codes. The correct code set
is determined by date of service.
 Note: The indicator entered must
align with the diagnosis code entered
in boxes 3 and 4.
 ICD-9 and ICD-10 codes may not be
mixed on the same claim form.
Certification
After reading the certification statement, the
provider must sign and date the form. The
signature must be an original signature and
not a stamp.
PR0076 V1.1 8/19/15
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