Billing Manual for Community Care Network Providers

11 Insured policy, Group or FECA Number (ifNot requiredapplicable)11a Insured’s Date of Birth and Sex Not required11b Employer’s Name or School Not required11c Insurance Plan Name or Program Name (if Not requiredapplicable)11d Is there another health benefit plan?(Check block Yes or No)RequiredIf Yes, return to and12 Member’s or Authorized Person’s SignatureAll invoices must have either the Recipient’ssignature or the words “Signature Exceptions”or “Signatures on File” and the datecomplete item 9a-dRequired13 Insured or Authorized Person’s Signature Not required14 Date of Current Illness Not required15 Date of Same or Similar Illness Not required16 Date Client Unable to Work in Current Occupation Not required17 Name of Referring Physician or Other Source (if Not requiredapplicable)17a Name of Referring Physician or Other Source Not required17b Referring Physician’s ID Not required18 Hospitalization Dates Related to CurrentServicesFROMRequired18 Hospitalization Dates Related to CurrentServicesTORequired19 Reserved for Local Use Not required20 Outside Lab Not requiredOutside Lab ChargesNot required21 Diagnosis Code ICD-9-CM BH Diagnosis Range Required290 – 319.21 Diagnosis Code 2 Not required21 Diagnosis Code 3 Not required21 Diagnosis Code 4 Not required22 Medicaid Resubmission Code/Original ReferralNumber required when submitting a correctedclaim.Required23 Prior Authorization Number Not required24A Date of ServiceRequiredFROM24A Date of ServiceRequiredTO24B Place of Service (See Community Care’s FeeSchedule)RequiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 107