How to fill Medicare part b sticker

INSTRUCTIONS FOR COMPLETING THE PART B STICKER

Complete the Medicare Part B/Medicaid-Title XIX sticker as follows and attach it to the RA/EOMB so it does not cover the recipient’s identifying information or claim payment information.

FIELD NUMBER & NAME
INSTRUCTIONS FOR COMPLETION
1.
Provider Name
Enter the provider’s name as shown on the provider label.
2.
Provider Medicaid Number
Enter the provider’s nine-digit Medicaid number.
3.
Recipient Name
Enter the recipient’s name exactly as shown on the ID card.
4.
Recipient Medicaid Number
Enter the recipient’s eight-digit identification number as shown on the ID card.
5.
Other Insurance Payment
Enter the amount paid by any other insurance. Do not show the Medicare payment here.
6.
Name Other Insurance Company
If an insurance amount is shown on line 5, enter name of insurance company.
7.
Patient Account Number
For the provider’s own information, a number may be entered here.
8.
Beneficiary HIC Number
Enter the patient’s HIC Number as shown on the Medicare card.
9. & 10.
Service Date: From and Through
Enter the date of service. If multiple dates of service are shown on the Medicare RA/EOMB for a single claim, enter the first chronological date of service in “From” field and the last chronological date of service in “Through” field.
11.
Billed
Enter the total billed dollar amount for the claim. Use the amount shown on the Medicare RA/EOMB.
12.
Allowed
Enter the total Medicare allowed amount for the claim. Use the dollar amount shown on the RA/EOMB.
13.
Paid
Enter the total dollar amount paid for the claim by Medicare.
14.
Paid Date
Enter the date shown at the top of the RA/EOMB.
*15.
Deductible
If any deductible was applied on this claim, enter the amount due in this field.
*16.
Coinsurance
Enter the total amount of coinsurance due on this claim.
17.
Blood Deductible
If there is blood deductible due, enter that dollar amount.