The EI-CBO will only accept the HCFA/CMS-1500 form and the UB-92 (HCFA-1450) form from providers billing for evaluations, assessments and direct services. Providers and Parents and/or Guardians who bill the EI-CBO for transportation services must use the DHS Transportation Billing Form. No other forms will be accepted.

All claim forms must be legible. They must be hand printed, typed or electronically printed. The EI-CBO will not make assumptions and will deny claims that are not legible. The claim forms must also be fully completed with the required data elements as stated in this section. Partially completed forms will be denied (Attachment E: Situation Code Meanings) or returned (Attachment F: Returned Claim Form) to the provider unpaid. Ditto marks are not acceptable.

Remember

  • A maximum of six (6) lines of service are allowed per claim form
  • Only one (1) discipline of service and one (1) provider are allowed per claim form
  • Bill using the Early Intervention codes identified in the EI Service Descriptions, Billing Codes and Rates booklet
  • Use HCPCS codes for Assistive Technology billing
  • All "miscellaneous" Durable Medical Equipment codes must include the description of the equipment
  • Type or print legibly the full name of the credentialed/enrolled person who provided the services or the full name of the credentialed/enrolled supervising provider and the name of the credentialed associate who provided the services
  • Early Intervention does not pay for therapists to provide services to a child/family via the telephone.
  • If the provider consults with the family via the phone, it is considered administrative time and is non-billable time. Refer to the Early Intervention Service Descriptions, Billing Codes and Rates document found on the DHS and EI-CBO web sites for more information regarding billable/non-billable time.

HCFA/CMS-1500 Requirements 

(Attachement B: CMS - 1500 Form Example)

  • Child's name (last and first) (field 2)
  • Child's complete address (field 5)
  • Six (6) digit EI number (field 1a)
  • Date of Birth (field 3)
  • Name of associate provider, if applicable (last name, first name) (field 19)
  • ICD-9 treatment diagnosis code (field 21 1-4.)
  • Date of service (one (1) per line in chronological order) (field 24 A)
  • Indicate the two (2) digit place of service (POS) location code (field 24 B)
    • 03 - Regular Nursery/Day Care (offsite)
    • 11 - Service Provider Facility (onsite)
    • 12 - Home (offsite)
    • 16 - Family Day Care (offsite)
    • 62 - Early Intervention Program (onsite)
    • 99 - Other Setting (offsite)
  • Procedure Codes identified on the authorization (24 D)
  • Amount billed (field 24 F)
  • Length of session in units (field 24 G)
  • Taxpayer identification number (payee tax ID) (field 25)
  • Patient Account number - if applicable (field 26)
  • Total Charge (field 28)
  • Name of enrolled provider who performed or supervised services and date (field 31)
  • Complete Payee name and address (field 33)

UB-92 Requirements 

(Attachment C: UB-92 Claim Form Example)

  • Complete Payee name and address (field 1)
  • Must include the taxpayer identification number (payee tax ID) (field 5)
  • Child's name (last and first) (field 12)
  • Child's complete address (field 13)
  • Date of Birth (field 14)
  • Description of service (field 43)
  • Bill using the Procedure Codes identified on the authorization for services (field 44)
  • Bill using HCPCS codes for Assistive Technology. Durable Medical Equipment codes described as "miscellaneous" must include the description of the equipment. (field 44)
  • Bill only one (1) date of service per line in chronological order (field 45)
  • Length of session/serv units (field 46)
  • Amount Billed (field 47)
  • Total amount billed (field 55)
  • Indicate the two (2) digit place of service (POS) location code (field 56)
    • 03 - Regular Nursery/Day Care (offsite)
    • 11 - Service Provider Facility (onsite)
    • 12 - Home (offsite)
    • 16 - Family Day Care (offsite)
    • 62 - Early Intervention Program (onsite)
    • 99 - Other Setting (offsite)
  • Six (6) digit EI number (field 60)
  • ICD-9 treatment diagnosis code (field 67)
  • Name of enrolled provider who performed or supervised services (field 84)
  • Name of associate provider, if applicable, under the supervising provider name (field 84)

DHS Transportation Billing Form Requirements 

(Attachment D: Example Transporation Billing Form)

  • Child's name and complete address
  • Child's (6) six digit EI number
  • Child's date of birth
  • Payee name and complete address
  • Payee tax ID number
  • Vehicle License Plate number
  • Bill only one (1) date of service per line in chronological order
  • For taxi and service car mileage code "A0425", enter the total loaded miles one way. When a round trip is provided two mileage procedure codes and service lines must be completed. The EI-CBO will no longer accept claims for mileage code A0425 that have been billed as a round trip on one service line.
  • For private auto mileage "A0090", enter the total loaded miles one way. When a round trip is provided two mileage procedure codes and service lines must be completed.
  • Enter the complete departure and destination addresses in the space provided.
  • Indicate the alpha code "D" (medical services) or "R" (residence) in the departure and destination code spaces provided.
  • Enter the departure and destination times in the space providedFor service car, taxi and private auto, bill for loaded mileage only. Loaded mileage means that the child is in the vehicle.
  • Enter the charge for each service lineEnter the total charges
  • Type or print legibly the full name of the enrolled transportation provider or company on the "Name of Enrolled Provider or Transportation Company" line and date the claim form.
  • Providers must read and agree to the billing/authorization information, parental rights and certifications on the back of the billing form.