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all right what's going on guys Tony here.so I want to show you how you can use.these two documents there are two PDFs.to generate your paper claims now this.is definitely not the best way to do it.the the gold standard for how you would.do this if you want to submit a paper.claim is you would go to the office Ally.website you'd create a free account.you'd create a free practice mate.account within office Ally and you.generate your CMS 1500s through the.practice mate software but I know some.of you guys are just getting started and.you're just looking for a quick resource.to generate a claim to get it out to the.consumer so I had these forms created.for you let's go through them I'm gonna.zoom in here a little bit there's.basically two forms they look exactly.the same this one when you go to print.it will print if you're using a black.and white LaserJet it'll print the red.in gray if you're using a color inkjet.it'll print it in red but I've got.another form here that like I said it.looks exactly the same but this one will.not print all the background it is.designed to print on a pre-printed CMS.1500 so let's go through this one let me.delete these boxes here I'm going to.zoom in a little bit now we'll just hit.everything that you're going to need so.you're gonna have to indicate that it's.a Medicare form pretty standard right.box number one box number two you're.gonna have the patient we're gonna and.it says last name first name middle.initial so Brady Thomas oops.J I don't know if that's really his.middle initial patients date of birth.Oh 201 1901 32 you need to indicate sex.you need to come down here.main street is what's the patient's.relationship to insured if it's a.Medicare it's gonna be self.let's finish Monroe Ohio that's where my.one of my clinics is located five one.three nine nine nine nine nine nine nine.okay right now so we've got one two.three four five force for force over.here assuming this is going to be the.same I'm gonna copy that over we're.assuming that the patient is the insured.which is the most common scenario and.the phone number okay we're going to.jump up here this is going to be the.subscriber ID number so on their.Medicare insurance card this is where.you're gonna find the member ID the.subscriber ID and and this applies guys.this isn't just for Medicare this.applies across the board commercial.payers out of network coverage whatever.it is you're submitting this is the the.gold standard for a super bill so let's.just say you know what let me open this.sample Medicare card just so you guys.know what it's gonna look like and it's.going to look something like this you'll.have the patient's name you'll have.their member ID Medicare number.subscriber ID one eg for now typically.when you're filling this out you don't.put the dashes in and you typically will.use all caps so one eg four and I'm just.gonna make up the rest of the letters.and numbers okay box number e will be.left blank box number nine this is gonna.be the secondary insurance information.now if there's a secondary which we're.not going to get into supplemental.Medigap or secondary there are some.distinctions but a most.it's going to be a supplemental or a.medigap I've got a video explaining that.that information is going to go in here.when you look on the card so other.insured's name if it's the same person.you're just gonna copy and paste their.name if it's a spouse you would put the.spouse's name other insurance policy or.group number so you would get their.subscriber ID member ID off the.secondary card I'm just gonna put a.number in there and then plan name so.let's say for example United Healthcare.okay so that takes care in number nine.number ten these are all going to be.indicated as no it's not an employment.workers comp situation it's not an auto.accident it's not an other accident you.don't have to place anything in the.state if you indicate no for those.number eleven insured's.policy group FECA number you don't need.any of that information you do need the.insurance date of birth.so we said they were born February 1st.30 to gender again this is just copying.over from what we had over here insured.plan or name a program can remain blank.is there another benefit yes in most.cases there will be another benefit this.is where when you insured or authorized.persons signature patient number 12.patient or authorized person signature.we'll deal with that when we print it.then down here number 14 leave it blank.number 15 leave it blank 16 leave it.blank.17 is required now DN is the qualifier.for a referring physician you there's.basically three options there's a.referring physician ordering physician.and supervising physician you are always.going to go with referring physician.you're always going to use DN in that.box here is we're going to put the name.of the physician so I'm just gonna say.this is a made-up name.Scot Smith you are gonna find the MPI.for dr. Smith and that again we're just.gonna make up an NPI so over here is 16.18 20 22 23 those all these boxes over.here are going to remain blank for the.ICD it's gonna be an icd-10 this is.where you're going to enter your icd-10.whoops icd-10 codes you will not enter a.period when you're submitting or any of.these claims so M 5 4 5 low back pain.let's say m 5 4 2 neck pain you know.your codes are going to get in there I'm.not going to get into coding and then.down here so this is where we begin.today is March 2nd Oh 302 20 and it's.you know this is going to be repeated.here place of service will be 11 if.you're treating the Medicare beneficiary.in your office 12 if you're treating the.Medicare beneficiary in the.beneficiary's home column see remains.blank your procedure code since I'm a.physical therapist let's say it was a.moderate complexity evaluation now for.your modifiers again I'm a physical.therapist so I'm going to enter a GP.modifier if this patient had met the.financial threshold for the year and I.needed to append the KX modifier the KX.would go right next to it but in this.case we're going to say they haven't the.diagnosis pointer under column E that is.going to correspond to the treatment.diagnosis so in this case I'm saying.we're treating neck and low back pain so.I'm going to give it a and B there are.situations where for an eval line item.you might only have a.diagnosed this pointer but then for.subsequent treatment line items you.might have two diagnoses pointers I.talked about that in my course I'm not.going to discuss it here but I just want.you to be aware that that's possible.when we come out here to charges so.let's say for this I'm gonna make it a.hundred dollar charge we're gonna make.it a single unit now as we come out here.to column J this is where the rendering.provider MPI is gonna go in so honestly.I don't know my MPI off the top of my.head so I'm just throwing random digits.in there but this is for the treating.therapist the treat not the organization.the billing organization the group MPI.this or the treating therapist MPI then.as we come down here you're gonna come.into your tax ID number and I'm gonna.put a n if you have a patient account.number it's going to go in here usually.what I do for a patient account number.we said Tom Brady so what I usually do.is I go TV and then I do 2020 March Oh -.you are gonna accept assignment let's.let's do let's throw another claim in.here so oops you know usually you are.rendering care on the same date of.service.let's say I'm doing whoops this is why I.say this is about the worst possible way.to submit claims because it will take.you forever and then let's hit one more.and I realize these don't line up they.don't have to line up exact but they.should line up Bose enough okay so a new.change to the CCI edits when you're.billing manual therapy on the same date.of service that your billing an.evaluation you have to append the 59.modifier so that's where the 59 modifier.would go I'm going to throw in the a B.I'm gonna say $50 single unit we're.gonna throw on the rendering therapist.NPI whoops okay so we've got that total.charges going to be two hundred and.fifty dollars zero paid last thing we're.gonna need so if and this you know.honestly this is something that your.accounting software will handle.generally speaking if I remember.correctly now it's been a long time when.you're submitting a claim and the.service facility location matches the.billing provider address you can leave.box 32 blank if you're submitting a.claim for services delivered in the home.you can leave box 32 blank if somebody.has updated information on that let me.know if your billing provider has a.different address than the billing the.facility location you would populate.both these boxes so for now I'm just.gonna go with five one three four two oh.nine nine nine nine.that is my clinic number total therapy's.solutions.and then we're gonna come down here you.would think I could tight and then you.need the group NPI right down here it's.not a real group mpi but that would be.where the group MPI goes now at this.point this claim is done ready to go you.would still need to sign if you're.authorized so I authorize the release of.any medical or other information.necessary process this claim I also.request payment this essentially gives.us the approval to submit the claim on.behalf of the patient or third person.you're insured signature authorize for.its payment of medical benefit to the.undersigned physician or supplier.service below when you get your.admission paperwork done and probably.need to look 12 and 13 let's jump down.here real quick again I have to find the.instructions on that that's typically.something you check the box on the claim.in your electronic medical record saw.I'm speaking so slow I'm trying to read.through this to see if I can find the.exact authorization on that service so.this is the provider signature all right.I'll come back in a second video and.I'll grab the resources or let me try.one more thing here.okay let's see what we've got.I hate to give you guys incomplete.information and you know what I'll.actually attach this I'll put this in.the video description.oh here we go instructions enter.signature on file sof or legal signature.if there's no signature on file leave.blank no signature on file okay so we.always have you will always have the.signature on file and number 12.enter signature on file patient okay so.there you go so signature on file in.both of those situations when legal.signature enter date signed in six or.eight digit format perfect so that's the.answer we're looking for alright guys.just so you can see what this looks like.so if I go to print this now I'm gonna.can you see that preview right there see.how it's printing blank I'm gonna just.just the current page I would in this.scenario put the pre-printed that I.ordered through Amazon and I'll put the.link in the video description below for.the Amazon CMS 1500 forms but basically.what's going to happen here I'm going to.let me see if I'm going to drop these in.a download folder all right so let's.make it test.and so here you go this is what it looks.like because it's going to print.unprepared.forms if you need the form to print.you're going to complete this one and.then when you go to print this one you.can see how it's going to be there we're.gonna do it if you're gonna do red ink I.highly highly encourage you to just go.ahead there we go.this is what it would print on a plain.white piece of paper you'd have the gray.grayish black background but if you're.gonna do the red ink I would encourage.you to just buy the pre-printed forms.but if not you have a laser jet laser.color or inkjet you can give it a shot.I'm not sure quite honestly if it would.work or not but you won't know until you.try all right guys that's the best I've.got for you hopefully this forums helped.you but again I would strongly strongly.encourage you to just go let me show you.real quick we're here go and I'll put.these links in the description also go.to office Ally once you get here you're.gonna go to resource center you're going.to go to office a life forms and manuals.you're gonna complete the authorization.sheet the BAA and the practice mayn't.user agreement that's it three forms.you're done they're super quick and easy.couple signatures everything is 100%.free now if you use practice mate and.office holidays submit claims.electronically office Allah is going to.charge you 35 a month per rendering.provider but you absolutely can use.practice mate to do all the patient.accounting print the CMS 1500s and then.mail a man until you have enough.caseload to justify paying the 35 a.month it's not an EMR it's a.clearinghouse and or an accounting.software so guys keep that in mind let.me know if you have any other questions.I appreciate you watching the video.I'll catch you guys in the next one.thanks a lot.

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Hcfa 2360 Fill In Form FAQs

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How do I fill out the IT-2104 form if I live in NJ?

Do you work only in NY? Married? Kids? If your w-2 shows NY state withholding on your taxes, fill out a non-resident NY tax return which is fairly simple. If it doesn't, you don't fill out NY at all. If it shows out NYC withholding you enter that as well on the same forms. Then you would fill out your NJ returns as well with any withholding for NJ. Make sure to put any taxes paid to other states on your reciprocal states (nj paid, on NY return and vice versa)

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Use these steps to help you decide what coverage you want: Step 1: Decide if you want Original Medicare or a Medicare Advantage Plan (Iike an HMO or PPO) expand icon You can choose Original Medicare. ... Step 2: Decide if you want prescription drug coverage (Part D) ... Step 3: Decide if you want supplemental coverage.

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