- Patient’s name and address
- Date(s) of service
- Type(s) of service(s) provided (CPT codes)
- Billed amount
- Provider’s license number, federal tax identification number (FEIN or SSN), business address, telephone number, signature or signature stamp
- Billing date
The surgeon, facility, and anesthesia fees are paid at 80% of the billed amount. Facility and anesthesia fees are subject to be reimbursed at the Medicare rate if the procedures are outsourced to a different facility and not completed in-house.