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The following fields are required to be filled in to insure expedient claims processing. Fields for which we have provided more detailed explanations are particularly important. Please make sure that you or your billing representative have a thorough understanding of the data required.
1a. Insured's I.D. Number
Member's PacifiCare Behavioral Health identification number.
2. Member's Name
3. Member's birth date
4. Insured's Name
This is the individual who is the policyholder with PacifiCare Behavioral Health.
5. Member's Address
6. Member Relationship to insured
7. Insured's Address
12. Medical Release
13. Payment Authorization
21. Diagnosis or nature of illness
Primary diagnosis must be from the most current printing of the DSM-IV.
24. A. Dates of Services
B. Place of Service
C. Type of Service
D. Procedures, services, or supplies
CPT code which best represents authorized services. Must be code recognized in most current standard edition of AMA's CPT reference book.
E. Diagnosis Code
F. Charges
G. Days or units
25. Federal Tax ID number or Social Security Number.
This number reflects what will be reported in the 1099 mailed to you each January for previous year's reimbursements.
26. Member's Account No.
27. Accept Assignment
28. Total Charge
29. Amount Paid
30. Balance Due
31. Signature of Physician
Your signature and date NEEDS to appear in this box. If you are using a xerox copy of the HCFA form, please sign in blue ink.
32. Name and Address of facility where services were rendered (other than home or office)
33. Physician's billing name, address, zip code and phone number.
Your name and the address to which payment/communication is to be sent. If this information has changed since you were credentialed, please notify Provider Network Management to avoid processing delays
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