Quick Guide to Required Billing Information

Required for All Requests
  • Patient's first and last name, address and social security number
  • Patient's phone number, including area code
  • Patient's sex
  • Patient's date of birth
  • Ordering physician's first and last name
  • Indicate billing type
  • Date of collection
Client Bill
  • Verify account and client code
Patient Bill
  • Patient's address
  • Patient's phone number, including area code
  • Patient's social security number
  • Patient's date of birth
  • Responsible party's name and address, if different than patient's
  • Responsible party's relationship to patient
  • Responsible party's social security number
Medicare
  • Patient's address
  • Patient's Medicare number
  • ICD-9 diagnosis code
  • Ordering physician's UPIN
  • An ABN should be obtained whenever the ordering physician has reason to believe that Medicare will not cover the requested test(s)
  • Copy of the front and back of the insurance card
Medi-Cal
  • Patient's address
  • Patient's Medi-Cal number
  • Ordering physician's state license number
  • ICD-9 diagnosis code
  • "S" diagnosis code(s) (HAP only)
  • Copy of the front and back of the insurance card
Other Third-Party Insurance (including HMO and PPO)
  • Insured's name and address
  • Insurance company and plan or product
  • Subscriber, contract and policy numbers
  • Group number or name
  • Relationship of insured to patient
  • ICD-9 diagnosis code or narrative
  • Ordering physician's state license number and UPIN
  • Copy of the front and back of the insurance card
Worker's Compensation Claims Need the Following Additional Information
  • Employer's name and address
  • Case number
  • Date of injury
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