Processing of Automated Multichannel Tests

Completion of the Blue Shield Claim Form

On the following page is a copy of the Blue Shield (HCFA 1500) claim form. Certain items which
need clarification are indicated below if you are filing hard copy because the claim can not be
filed electronically:

1a. List the identification number as shown on the patient's identification card making sure to include the alpha prefix.

5. Be sure to list the complete address, including zip code. List telephone number.

10. Check the Yes or No block when applicable.

17. If you are billing for a service as a result of a referral, indicate the name and unique physician identification number (UPIN) of the referring physician.

21. List each ICD-9 diagnosis code for which services were rendered.

24A. Enter month, day, and year for each service rendered. If like services are rendered over consecutive dates of service, enter the beginning and ending dates of treatment in the appropriate "From" and "To" spaces. If the dates of service are not consecutive, each date should
be filed separately.

24B Insert a two-digit place of service code to indicate where the physician treated the patient.

24C Insert a one-digit type of service code.

24D. Use the applicable five-digit CPT or HCPCS procedure code to describe the service
rendered. Any modifiers applicable should be noted here.

24G Insert the correct number of days or units.

27 Payment for an assigned claim is made directly to the physician. Payment for non-assigned claims goes to the patient and the physician can receive only limited information on the status of the claim.

29. Amount paid should always be left blank. Any amounts listed in this field are deducted from payments that may be made to the provider

30. Balance should always be left blank. Amounts due will be determined from the charges and
application of copayments and deductibles.

31. The physician must sign and date the claim (actual or stamped) or the claim must be signed by an authorized representative as prearranged with Blue Cross and Blue Shield of Alabama.

32. Complete when services are performed outside the physician's office or services are rendered in an institution. If services are performed outside the physician's office, list the name and address of location where services were rendered.

33. The PIN is the provider number. Example 51000009ABC. The provider number should be listed here on every claim.

Last Updated November 2007