| FORM FIELD | REQUIRED | DESCRIPTION |
| Form Locator 01 Provider Name, Address, and Telephone Number | YES | Enter the name of the provider submitting the claim and the complete mailing address. The minimum requirement is the providers name, city, state, and Zip code. The name in Form Locator 1 should correspond with the provider number in Form Locator 51. |
| Form Locator 02 ERO Assigned Number | | |
| Form Locator 03 Patient Control No. | | |
| Form Locator 04 Type of Bill | YES | |
| Form Locator 05 Fed. Tax No. | YES | Enter Tax ID Information |
| Form Locator 06 Statement Covers Period (From - Through) | YES | Enter the first date of service (DOS) in the "from" column and the last DOS in the "through" column. The dates may not span more than one calendar month. Enter both dates in MM/DD/YY Format (e.g., January 2, 2004, would be 010204). |
| Form Locator 07 Cov D. | YES | Enter the total number of days covered by the primary payer, as qualified by the payer organization. |
| Form Locator 08 N-C D. | | |
| Form Locator 09 C-I D. | | |
| Form Locator 10 L-R D.) | | |
| Form Locator 11 Unlabeled Field | | |
| Form Locator 12 Patient Name | YES | Enter the recipients last name, first name, and middle initial. |
| Form Locator 13 Patient Address | YES | Enter the detention facilitys address where the recipient resides. If recipient in custody of Border Patrol, enter the Border Patrol Station of the Border Patrol Officers. Do not use the detainee's home address. |
| Form Locator 14 Birthdate | YES | |
| Form Locator 15 Sex | YES | |
| Form Locator 16 Marital Status | | |
| Form Locator 17 Admission Date | YES | |
| Form Locator 18 Admission Hr | | |
| Form Locator 19 Admission Type | YES | |
| Form Locator 20 Admission Src | YES | |
| Form Locator 21 D Hr | | |
| Form Locator 22 Stat | YES | |
| Form Locator 23 Medical Record No. | | |
| Form Locator 24-30 Condition Codes | YES | |
| Form Locator 31 Unlabeled Field | | |
| Form Locator 32-35 a-b Occurrence Code and Date | | |
| Form Locator 36 a-b Occurrence Span Code (From - Through) | | |
| Form Locator 37 A-C Internal Control Number/Document Control Number | | |
| Form Locator 38 Responsible Party Name and Address | YES | Enter: Immigration Health Services 1220 L St., NW PMB 468 Washington, D.C. 20005 |
| Form Locator 39-41 a-d Value Code and Amount | YES | |
| Form Locator 42 Rev. Cd. | YES | Enter the appropriate national four-digit revenue code. Enter the DOS in MM/DD/YY Format in Form Locator 43 or Form Locator 45. When series billing (i.e., billing from two to four DOS on the same line), indicate the DOS in the following Format: MM/DD/YY MM/DD MM/DD MM/DD. Indicate the dates in ascending order. Providers may enter up to four DOS for each revenue code if: All DOS are in the same calendar month. All procedures performed are identical. All procedures were performed by the same provider. If it is necessary to indicate more than four DOS per revenue code, indicate the dates on the subsequent lines. On paper claims, no more than 23 lines may be submitted on a single claim including the "Total Charges" line. |
| Form Locator 43 Description | YES | Enter the appropriate description for the national four-digit revenue code |
| Form Locator 44 HCPCS/Rates | YES | Enter the single most appropriate procedure code for every revenue code on every outpatient claim |
| Form Locator 45 Serv. Date | YES | Enter the DOS in MM/DD/YY Format in Form Locator 45.
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| Form Locator 46 Serv. Units | YES | Enter the number of covered visits, when appropriate. |
| Form Locator 47 Total Charges | YES | Enter the usual and customary charges pertaining to the related revenue code for the current billing period as entered in Form Locator 6, "statement covers period." |
| Form Locator 48 Non-covered Charges | | |
| Form Locator 49 Unlabeled Field | | |
| Form Locator 50 A-C Payer | YES | Immigration Health Services |
| Form Locator 51 A-C Provider No. | | |
| Form Locator 52 A-C Rel Info | | |
| Form Locator 53 A-C Asg Ben | | |
| Form Locator 54 A-C & P Prior Payments | | |
| Form Locator 55 A-C & P Est Amount Due | YES | |
| Form Locator 56 Unlabeled Field | | |
| Form Locator 57 Unlabeled Field | | |
| Form Locator 58 A-C Insureds Name | YES | |
| Form Locator 59 A-C P. Rel | | |
| Form Locator 60 A-C Cert. - SSN - HIC. - ID No. | YES | All claims require one of the following recipient numbers in order for processing. Enter the recipients Alien Identification Number. If not available, enter recipient's Fingerprint ID Number. If not available, enter recipient's Event Number. Do not enter any other numbers or letters. It is the referring custodial facility's responsibility to provide this information to the provider. |
| Form Locator 61 A-C Group Name | | |
| Form Locator 62 A-C Insurance Group No. | | |
| Form Locator 63 A-C Treatment Authorization Codes | YES | Enter the Authorization # for service. All Claims require an Authorization # for processing. It is the referring custodial facility's responsibility to provide this information to the provider. |
| Form Locator 64 A-C ESC | | |
| Form Locator 65 A-C Employer Name | | |
| Form Locator 66 A-C Employer Location | | |
| Form Locator 67 Prin. Diag Cd. | YES | Enter the full most current edition International Classification of Diseases, Clinical Modification (up to five digits) code describing the principal diagnosis (e.g., the condition established after study to be chiefly responsible for causing the admission or other health care episode). |
| Form Locator 68-75 Other Diag. Codes | YES WHEN APPLICABLE | |
| Form Locator 76 Adm. Diag. Cd. | YES | |
| Form Locator 77 E-Code | | |
| Form Locator 78 Race/Ethnicity | | |
| Form Locator 79 P.C. | | |
| Form Locator 80 Principal Procedure Code and Date | YES WHEN INPATIENT ONLY | |
| Form Locator 81 Other Procedure Code and Date | | |
| Form Locator 82 a-b Attending Phys. ID | YES | Enter attending pysician's name. |
| Form Locator 83 a-b Other Phys. ID | | |
| Form Locator 84 a-d Remarks | | |
| Form Locator 85 Provider Representative | YES | The provider or the authorized representative must sign in Form Locator 85. Note: The signature may be a computer-printed or typed name and date, or a signature stamp with the date. |
| Form Locator 86 Date | YES | Enter the month, day, and year on which the claim is submitted. The date must be entered in MM/DD/YY or MM/DD/YYYY Format. |
