West Virginia > Workers Comp
Services Invoice BI-400 - West Virginia
| Services Invoice Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-400 01/06 Service Invoice PLEASE CHECK THE APPROPRIATE BOX: BrickStreet Mutual Insurance P.O. Box 3151, Charleston, WV 25332 1. Claimant name (Last, First, Middle) 3. Employer business name 5. Claimant Social Security Number 8. Referring physician's provider number COMPLETE ALL INFORMATION REQUESTED UNLESS OTHERWISE NOTED. T YPE O R PRI N T L E G IB L Y Coal-Workers' Pneumoconiosis Fund P.O. Box 564, Charleston, WV 25332 2. Claimant address (Street or P.O. Box, City, State, Zip) 4. Employer mailing address 6. Date of injury 9. Referring physician's name 7. Claim number 10. Date c laimant first consulted provider for this condition 11. Diagnosis Code (ICD-9-CM) (1) (2) (3) 12. Authorization number 13. Check this block if emergency 18. Payee number Description 14. Provider account numbe r 19. Payee name and address 15. Provider FEIN number 16. Provider number 17. Check this block if payment is to be made to the claimant 20. Service Date 21. Procedure Code 22. Mod Code 23. Description 24. Charges 25. Units 26. P.O.S. 27. Dental Tooth No. 28. As provided by statute, this is to certify that the services were rendered as outlined above and that no other or additional charge for such treatment, appliance, or service has been or will be made against any person, firm, or corporation. 29. Total Charge 30. Amount Paid 31. Balance Due Provider or Claimant Signature 32. Provider Name/Address Date 33. Remarks 34. Provider Phone Number 35. Provider UPIN/NPI BrickStreet Mutual Insurance Charleston, WV American LegalNet, Inc. www.USCourtForms.com Instructions for Completing the Service Invoice (BI-400) Complete all information requested unless otherwise noted. TYPE OR PRINT LEGIBLY. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. CLAIMANT NAME: Enter the Claimant's last name, first name, and middle initial with the spelling exactly as it appears on his/her compensability approval letter or social security card. CLAIMANT ADDRESS: Enter the Claimant's full mailing address including street number, post office box, or rural route number, city, state, and zip code. EMPLOYER BUSINESS NAME: Enter the name of the employer for which the Claimant was working on the day of injury or date of last exposure. EMPLOYER MAILING ADDRESS: Enter the full address for the employer listed in Block 3. CLAIMANT SOCIAL SECURITY NUMBER: Enter the social security number of the Claimant. DATE OF INJURY: In an injury claim, this is the date the Claimant was injured. In an Occupational Pneumoconiosis or disease claim, this is the date of last exposure. CLAIM NUMBER: The number assigned to the claim by BrickStreet Insurance. This number is found on the Claimant's compensability approval letter. REFERRING PHYSICIAN'S PROVIDER NUMBER: If known, enter the authorized physician's provider registration number. If the number is unknown, Block 9 should be completed. REFERRING PHYSICIAN'S NAME: Enter the name of the physician listed in Block 8. DATE CLAIMANT FIRST CONSULTED PROVIDER FOR THIS CONDITION: Enter the date the provider first treated the Claimant for the diagnosis in Block 11. DIAGNOSIS CODE/DESCRIPTION: Using the appropriate ICD-9-CM numeric code, list the Claimant's primary diagnosis followed by the written description of the condition. The ICD-9-CM numeric code is listed on the BrickStreet ID card which is issued to the Claimant. Prefix codes "E" and "M" are not acceptable. AUTHORIZATION NUMBER: Services that require prior authorization must have an authorization number. This number appears on the letter sent to the Claimant granting authorization for the service or procedure. There is no number for an Occupational Pneumoconiosis examination. IF EMERGENCY, CHECK THIS BLOCK: Check this block if services were rendered on an emergency basis only. PROVIDER ACCOUNT NUMBER: Enter the account number assigned to the Claimant by the provider's office. Information listed in this field will be entered and reported on the provider's Remittance Advice. PROVIDER NUMBER: Enter the Federal Employer Identification Number (FEIN). In addition, some providers may need to enter a two- digit office location code, if notified by BrickStreet. 16. PROVIDER REGISTRATION NUMBER: Provider's personal identification number assigned by BrickStreet Insurance. 17. CHECK THIS BLOCK IF PAYMENT IS TO BE MADE TO THE CLAIMANT: If payment is to be made to the Claimant, check this block. 18. PAYEE NUMBER: This block must be completed if the services were provided by an office, business, or individual whose reimbursement payments should be made to another party, such as a parent company, hospital, or practice group. 19. PAYEE NAME AND ADDRESS: If Block 17 is completed, list the payee's name and address. 20. SERVICE DATE: Enter the date on which the service was provided in MM/DD/YY format, such as 06/09/99 for June 9, 1999. 21. 22. 23. 24. 25. 26. PROCEDURE CODE: Enter the appropriate CPT4, HCPCS, or ADA procedure code for the service billed. MODIFIER CODE: Enter the appropriate modifier when required. DESCRIPTION: Provide a narrative description of the procedure listed in Block 20. Abbreviations and short descriptions are acceptable. CHARGES: Enter the total charge for each procedure code used. UNITS: Enter the number of units for the procedure or service listed in Block 20. PLACE OF SERVICE (POS) CODE: Enter the appropriate place of service code from the list provided. Code 11 12 21 22 23 24 25 26 31 32 Description Office Home Hospital (Inpatient) Hospital (Outpatient) Hospital (Emergency Dept.) Ambulatory Surgical Center (ASC) Birthing Center Military Treatment Facility Skilled Nursing Facility Nursing Facility Code 33 34 41 42 51 52 53 54 55 56 Description Custodial Care Facility Hospice Ambulance (Land) Ambulance (Air and Water) Psychiatric Facility (Inpatient) Psychiatric Facility (Outpatient) Community Mental Health Center Intermediate Care Facility Residential Substance Abuse Facility Psychiatric Residential Treatment Center Code 60 61 62 65 71 72 81 99 Description Mass Immunization Center Comprehensive Inpatient Rehab Center Comprehensive Outpatient Rehab Facility End Stage Renal Treatment Facility State or Local Public Health Clinic Rural Health Clinic Independent Lab Other Unlisted Facility 27. 28. 29. 30. 31. 32. 33. 34. 35. DENTAL TOOTH NUMBER: Dental only -list tooth number. PROVIDER OR CLAIMANT SIGNATURE: The invoice must be signed by the provider or a legally responsible designee or the Claimant. Signature stamps are acceptable. DATE: Enter
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