CM 11 2012
RECORD OF BILLED SERVICES
|LAST NAME: | |FIRST NAME: | |
|DOB: | |MEDICAID NUMBER: | |
|ADDRESS: | |CITY: | |ZIP: | |
|PRIMARY DIAGNOSIS: | |ICD-9 CODE: | |
|CASE MANAGER TPI NUMBER: | |AUTHORIZATION NUMBER: | |
|NUMBER OF AUTHORIZED SERVICES: |COMPREHENSIVE | |FACE-TO-FACE | |TELEPHONE FOLLOW-UP| |
| | | |FOLLOW-UP | | | |
|EFFECTIVE DATES |FROM: | |TO: | |
|BILLED SERVICES |
|(ALL SERVICES USE PROCEDURE CODE G9012) |
|DOS |POS |MODIFIERS |CASE MANAGER’S SIGNATURE |CLAIM STATUS |
| | |U2 & U5 = COMPREHENSIVE | |DATE FILED |PAID? |R&S # |
| | | | | |Y or N | |
| | |TS & U5 = FACE TO FACE FOLLOW-UP | | | | |
| | |TS = TELEPHONE FOLLOW-UP | | | | |
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DOS = DATE OF SERVICE POS = PLACE OF SERVICE R&S = REMITTANCE AND STATUS REPORT
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