Basic Rules for Completing Blank Non-Institutional 081 Claim Forms

There are some basic rules to follow before completing the claim form.

·  Make sure the Non-Institutional 081 is the right form to use for the claim.
·  Enter all information using black type or a pen using black ink. (The fiscal agent can only process clean claims with black type or ink. Use only black ink on adjusted claims to indicate the item being corrected.)
·  Be sure the information on the form is legible.
·  Enter information within the allotted spaces.
·  Do not use whiteout.
·  Complete the form using the service-specific Coverage and Limitations Handbook as a reference

Before Completing the Form
Before filling out a claim form, answer the following questions:
·  Was the recipient eligible for Medicaid on the date of service?
·  Has the recipient’s eligibility been verified?
·  Was a MediPass or HMO authorization obtained, if applicable?
·  Was the service or item covered by Medicaid?
·  Was the service in the recipient’s plan of care?
·  Was the case manager’s authorization obtained, if applicable?
·  Has a claim been filed, and a response received, for all other insurance held by the recipient?

If all of the above information is not available, review the instructions in this handbook.

If the response to all of the above questions is “yes,” fill out the claim form following the step-by-step instructions for each item on the form.

Recipient’s Name 

Enter the recipient’s last name, first name, and middle initial exactly as it appears on the gold, plastic Medicaid identification (ID) card or other proof of eligibility

Medicaid Identification Number

Enter the recipient’s ten-digit Medicaid ID number. Do not enter the number on the Medicaid ID card. This is a card control number, not the recipient’s Medicaid ID number.