Example B:  Individual provider employed by a group

Example C:  Entity (e.g., Ambulatory Surgery Center (ASC), Laboratory, Portable X-ray, Independent Diagnostic Testing Facility (IDTF), Ambulance supplier)

• The ASC/Lab/IDTF Federal Employer identification Number (FEIN) can be indicated in Item 25
• The NPI assigned to the entity must be indicated in Item 33a
  • Nothing should appear in Item 24J

There has also been some confusion regarding Items 32, 32a and 32b. Points to keep in mind:

• Enter the name, address and zip code of the service location in Item 32 for all services other than those furnished in place of service Home – code 12
• Providers of service shall identify the supplier's name, address and zip code in Item 32 when billing for purchased diagnostic tests (see Item 20)
• In Item 32a, the only time an NPI should be indicated is when you are billing for purchased diagnostic tests. This coincides with Item 20.

Example D:  Claims for purchased diagnostic tests

• Indicate 'yes' and the amount you paid for the service in Item 20
• Identify the supplier’s name, address and zip code in Item 32
• Include the supplier’s NPI in Item 32a

If you need assistance completing other areas of the claim form, the Palmetto GBA Interactive CMS-1500 Claim Form will be a great tool for you. Access the form directly from the home page for your state or jurisdiction:

• Jurisdiction 1 Providers
• Ohio
• South Carolina
• West Virginia

If you are an electronic submitter and need help identifying the fields on a paper claim form within your electronic format, please refer to the CMS-1500 Claim Form Crosswalk to ANSI 4010a1 located in the Palmetto GBA Physician/Supplier Guide.

Other questions can be directed to our Provider Contact Centers: 

• Jurisdiction 1: (866) 931-3901
• Ohio and West Virginia: (866) 332-7025
• South Carolina: (888) 828-2092

Attention Sole Proprietors
Today, sole proprietors are issued only one NPI (for a Type 1 – Individual) and one PTAN. You should follow Example A above for NPI placement.

Sole Proprietors who have been enrolled in the Medicare system for a number of years may have been issued two PTANs and, therefore, applied for two NPIs (a Type 1 – Individual and a Type 2 – Organization). If this is the case, please follow Example B above.

Note: Sole Proprietors with two NPIs and two PTANs should contact Palmetto GBA to discuss steps necessary to update your enrollment file to the new/current method of enrolling Sole Proprietors.

Attention Sole-Owned Businesses and Incorporated Organizations
Today, sole-owned businesses and incorporated organizations are issued two NPIs (a Type 1 – Individual and a Type 2 – Organization) and, therefore, are issued two PTANs. Those who are enrolled this way should follow Example B above for NPI placement.

Sole-owned businesses and incorporated organizations that have been enrolled in the Medicare system for a number of years may have been issued one PTAN and one NPI. If this is the case, please follow Example A above.

Note: Sole-owned businesses and incorporated organizations that have only one PTAN and one NPI should contact Palmetto GBA to discuss steps necessary to update your enrollment file to the new/current method of enrolling sole-owned businesses and incorporated organizations.

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