GENERAL INFORMATION
The following providers must use the ASC X12N 837 5010 professional format when submitting electronic claims and the CMS 1500 claim form for paper claims.
* Ambulance
* Ambulatory Surgical Centers
* Anesthesiologist Assistants
* Certified Nurse Midwives
* Certified Nurse Practitioners
* Certified Registered Nurse
Anesthetists
* Chiropractors
* Community Mental Health Services Programs/Prepaid Inpatient Health Plans
* Family Planning Clinics
* Federally Qualified Health Centers
* Hearing Aid Dealers
* Hearing Centers
* Independent Laboratories
* Indian Health Centers
* Maternal Infant Health Program
* Medical Clinics
* Medical Suppliers
* Optical Companies
* Optometrists
* Oral-Maxillofacial Surgeons
* Orthotists and Prosthetists
* Physician Assistants
* Physical Therapists
* Physicians (MD & DO)
* Podiatrists
* Private Duty Nurses (Individually Enrolled)
* Rural Health Clinics
* School Based Services
* Shoe Stores
* Urgent Care Centers
Claims for services rendered as a result of an order or referral must contain the name and individual NPI of the provider who ordered or referred the service/item. The following are the authorized health professionals who may order, prescribe or refer services to Medicaid beneficiaries:
* Physician
* Physician Assistant
* Nurse Practitioner
* Certified Nurse Midwife
* Dentist
* Podiatrist
* Optometrist
* Chiropractor (limited to spinal x-rays only)
Examples of services that require an order, prescription or referral include, but are not limited to,:
* Ambulance non-emergency transports
* Ancillary services for beneficiaries residing in nursing facilities (e.g., chiropractic, dental, podiatry, vision)
* Childbirth/parenting and diabetes self-management education
* Consultations
* Diagnostic radiology services, unless rendered by the ordering physician
* Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
* Hearing and hearing aid dealer services
* Home health services
* Hospice services
* Laboratory services
* Certain mental health and substance abuse children's waiver services
* Certain Maternal Infant Health Program (MIHP) services
* Pharmacy services
* Private Duty Nursing services
* Certain School Based Services
* Therapy services (occupational therapy (OT), physical therapy (PT) and speech)
* Certain vision supplies
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