For 10a – 10c, required status is contingent upon a definitive “Yes” or “No” answer. If you are unsure, leave blank. Check "YES" or "NO" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in item 24. The state postal code, (i.e. MO) must be shown. Any item checked "YES" indicates there may be other insurance primary to Medicare. Primary insurance information must then be shown in item 11.

If you are unsure, leave blank.

Enter the phrase SIGNATURE ON FILE, or include legal signature (and date) of patient or authorized person.

In lieu of signing the claim, the patient must sign a statement to be retained in the provider, physician, or supplier’s file in accordance with Chapter 1 "General Billing Requirements". If the patient is physically or mentally unable to sign, a representative specified in Chapter 1 "General Billing Requirements" may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by "by" the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement.

Note: This can be "Signature on File" and/or a computer generated signature.For date fields other than date of birth, all fields must be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

Enter the phrase SIGNATURE ON FILE, or include legal signature (and date) of patient or authorized person. If neither, leave blank or state no signature on file.

The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if the required Medigap information is included in ltem 9 and its subdivisions. The patient or his or her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization (See Signature on File beginning on p. 3.S.1.) The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Note: This can be "Signature on File" and/or a computer generated signature.For date fields other than date of birth, all fields must be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

NOTE: Field required for Ancillary Claims.

Enter the referring, ordering or supervising provider’s first name, middle initial, last name and credentials. This field is required only if there is a referring, ordering or supervising provider.

• This section may be used for an unlisted procedure code when explanation is required and clinical review is required.
• If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be listed.
• Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits
• All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.
• Anesthesia start and stop times
• Itemization of miscellaneous supplies, etc.

Select "Yes." Note: Only if the provider participates with Medicare Universal Healthcare.

The following providers of service/suppliers and claims can only be paid on an assignment basis:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services, Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals.

Enter the location where the services were rendered. The provider of service must identify the
supplier’s information when billing for purchased diagnostic tests.

Note: Required when different from Billing Provider. Per the NUCC Instruction Manual, Field 32 is required if Field 20 is checked “yes.”

For more information, see the National Uniform Claim Committee’s Web site at www.nucc.org.