Number of approved in-center dialysis stations V26 25. Additional stations being requested In-center PD V31 FORM CMS-3427 Revision 05/13 V28 None V24 Onsite home training room s provided V27 2. If your state requires a Certificate of Need CON for an initial ESRD or for the change you are requesting mark the applicable box in Item 32 and include a copy of the documentation of the CON approval. Upon completion forward a copy of form CMS-3427 Part I to the State agency. 40. Surveyor Team Leader sign 41. Name/Number print 42. Professional Discipline Print 43. Survey Exit Date INSTRUCTIONS FOR FORM CMS-3427 PART 1 DOCUMENTATION NEEDED TO PROCESS FACILITY APPLICATION/NOTIFICATION TO BE COMPLETED BY APPLICANT A completed request for approval as a supplier of End Stage Renal Disease ESRD services in the Medicare program Part I Form CMS-3427 must include A narrative statement describing the need for the service s to be provided and A copy of the Certificate of Need approval if such approval is required by the state. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0360 END STAGE RENAL DISEASE APPLICATION AND SURVEY AND CERTIFICATION REPORT PART 1 APPLICATION TO BE COMPLETED BY FACILITY 1. Type of Application/Notification check all that apply if Other specify in Remarks section Item 33 V1 1. Initial 2. Recertification 6. Other specify 3. Relocation 4. Expansion/change of services 5. Change of ownership 2. Name of Facility 3. CCN 4. Street Address 5. NPI 6. City 7. County 8. Fiscal Year End Date 9. State 10. Zip Code 11. Administrator s Email Address 12. Telephone No* 13. Facsimile No* 14. Medicare Enrollment CMS 855A completed Yes No NA 15. Facility Administrator Name Address City 16. Ownership V2 1. For Profit 2. Not for Profit 3. Public 17. Is this facility owned and managed by a hospital and on the hospital campus i*e* hospital-based V3 1. Yes 2. No Is this facility owned and managed by a hospital and located off the hospital campus i*e* satellite V4 If owned and managed by a hospital hospital name V6 CCN V7 If Yes SNF/NF name V9 CCN V10 1. No 2. Yes Owned 3. Yes Managed If Yes name of multi-facility organization V12 Multi-facility organization s address 20. Current Services check all that apply V13 1. In-center Hemodialysis HD 2. In-center Peritoneal Dialysis PD 5. Home HD Training Support 21. New services being requested check all that apply 1. N/A 2. In-center HD 3. In-center Nocturnal HD 4. Reuse 7. Home Training Support only V14 22. Does the facility have any home dialysis PD/HD patients receiving dialysis in long-term care LTC facilities LTC SNF/NF facility name V16 V15 Staffing for home dialysis in LTC provided by V18 Type of home dialysis provided in this LTC facility V19 1. This dialysis facility 1. HD 2. LTC staff 2. PD For additional LTC facilities record this information and attach to the Remarks item 33 section* 23. Number of dialysis patients currently on census In-Center HD V20 In-Center Nocturnal HD V21 Home PD V23 Home HD 3x/week 24.
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Welcome to go beyond learning experiences to code Metro our goal in creating this series is to Pryor with tangible oftentimes little-known tips that you can apply to both your business and your career our topics will vary as will our speakers, and we welcome you to visit our website to get the latest edition of go beyond we appreciate your feedback and invite you to send us your thoughts and questions as well as any suggestions you might have for future topics our first edition of go beyond focuses on tips for completing the CMS 1500 form for faster payment our presenter today is our own chief operating officer Dr. kim finger kim has an extensive background in autism having served as a direct service provider in Connecticut many years ago after which she swayed into the world of executive coaching prior to joining code Metro Kim was the chief operating officer at autism spectrum therapies a large California-based autism services company Kim created the insurance billing department at code Metro and is here to share with you her tips on completing the 1500 form hello it's my pleasure to share with you our tips on how to successfully complete a CMS 1500 form a question were frequently asked by our customers is which fields on the 1500 form must be completed for the CMS form to be accepted and not rejected by the insurance carrier, so today we're going to answer this question as well as review which fields are optional to complete and which can be left blank we'll also be reviewing what information is entered in each of the mandatory and optional fields recognizing that the language on the 1500 form is foreign to most providers and a source of confusion when preparing the form okay let's take a look at the 1500 form there are 33 fields on the form of which two fields can always be left blank without worry and that's field 10d reserved for local use and field 15 if patient has had same or similar illness give first date now that we have those out of the way let's talk about the fields that must be completed to submit a clean claim before we go through the numbered fields let's start with entering the name and address of the insurance company in the top right-hand corner of the form although you may be submitting the form electronically the name and address of the insurance carrier must be included in this space on the form itself field 1a is a required field in this field you will enter the patient's insurance policy number as indicated on their insurance card in some cases the card will be in the parents name and their policy number will be entered here the ID number though will reflect not the parent but the patient's insurance ID number fields 2 camp; 5 capture patient name and address and must be completed the only optional.
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