PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 02-12 CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE NUCC 02/12 PICA MEDICAID TRICARE ID /DoD GROUP HEALTH PLAN ID CHAMPVA Medicaid Member ID FECA BLK LUNG 3. PATIENT S BIRTH DATE DD YY MM 2. PATIENT S NAME Last Name First Name Middle Initial F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE ZIP CODE 4. INSURED S NAME Last Name First Name Middle Initial SEX M 5. PATIENT S ADDRESS No* Street Child Spouse For Program in Item 1 7. INSURED S ADDRESS No* Street Other 8. RESERVED FOR NUCC USE TELEPHONE Include Area Code 9. OTHER INSURED S NAME Last Name First Name Middle Initial 10. IS PATIENT S CONDITION RELATED TO 11. INSURED S POLICY GROUP OR FECA NUMBER a* EMPLOYMENT Current or Previous a* INSURED S DATE OF BIRTH b. AUTO ACCIDENT PLACE State c* OTHER ACCIDENT c* INSURANCE PLAN NAME OR PROGRAM NAME NO YES 10d. CLAIM CODES Designated by NUCC d. IS THERE ANOTHER HEALTH BENEFIT PLAN READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim* I also request payment of government benefits either to myself or to the party who accepts assignment below. 15. OTHER DATE 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE If yes complete items 9 9a and 9d. SIGNED 17a* QUAL* 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. DATE 14. DATE OF CURRENT ILLNESS INJURY or PREGNANCY LMP b. OTHER CLAIM ID Designated by NUCC PATIENT AND INSURED INFORMATION MEDICARE Medicare OTHER 1a* INSURED S I. D. NUMBER 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17b. NPI 19. ADDITIONAL CLAIM INFORMATION Designated by NUCC 20. OUTSIDE LAB 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below 24E 22. RESUBMISSION CODE ICD Ind. A. B. C. F* G* ORIGINAL REF* NO. D. E* CHARGES H. J* DATE S OF SERVICE From To PLACE OF SERVICE EMG K. L* D. PROCEDURES SERVICES OR SUPPLIES Explain Unusual Circumstances MODIFIER CPT/HCPCS DIAGNOSIS POINTER I. RENDERING PROVIDER ID. EPSDT ID. Family Plan QUAL* DAYS OR UNITS NPI 25. FEDERAL TAX I. D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT For govt. claims see back 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS I certify that the statements on the reverse apply to this bill and are made a part thereof* 32. SERVICE FACILITY LOCATION INFORMATION a* NUCC Instruction Manual available at www. nucc*org b. 28. TOTAL CHARGE 33. BILLING PROVIDER INFO PH 30. Rsvd for NUCC Use 29. AMOUNT PAID PHYSICIAN OR SUPPLIER INFORMATION 24. PATIENT S BIRTH DATE DD YY MM 2. PATIENT S NAME Last Name First Name Middle Initial F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE ZIP CODE 4. INSURED S NAME Last Name First Name Middle Initial SEX M 5. PATIENT S ADDRESS No* Street Child Spouse For Program in Item 1 7.
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How to prepare Form CMS 1500 Claim
About Form CMS 1500 Claim
Refer to the following sample completed claim and quick reference to assist you in completing a CMS 1500. Completing a CMS 1500 Claim Form. Claim and Coverage Status Claims may be submitted to the CMS by email and telephone, from home, or by fax. The system that processes claims does not make the determination as to what is coverage under the Affordable Care Act (ACA), including the exclusion of certain plans, or not coverage that may apply under ACA provisions. For claims submitted by phone, call toll-free. For claims submitted online or by fax, use the following instructions to submit a claim with CMS: Fill-Out CMS Claim Form (CMS-1500) Complete the Claim Form — Quick Reference (CMS-1500-Quick Reference) Enter any Medicare beneficiary ID numbers, e-mail addresses, and phone numbers associated with the claims' submission (incomplete and incorrect telephone numbers may result in erroneous claims being filed). Complete a CMS Home Payment Claim Form — Quick Reference (CMS-1500-Home Payment Claims) Complete the CMS Home Payment Claim Form and submit it to your insurance carrier. You can also access to CMS Home Payments by accessing the CMS Home Payment Claim Form (PDF). Complete any additional optional instructions or provide additional information on the Claim Form (CMS-1500-Quick Reference). The CMS Home Payments system will generate a claim number indicating that a Claim Form was successfully submitted and any additional information you need. A Claim Form will be sent by email to the claims' submission email address(s) and to the address you provided on the claim form. (You may also choose to have the claim number sent to one or multiple locations in the United States.) Check your email account for a claim number. The CMS Home Payments system will provide you with an email message from the claims' submission email address (invalid or unapproved claim numbers will NOT be issued). Complete Claims for Medical Services Using a CMS Home Payment Claim Form — Quick Reference (CMS-1500-Home Payment Claims) Complete an online claim form (CMS-1500-Home Payment Claims) Complete the CMS Home Payment Claim form and submit it to your insurance carrier. You can also access to CMS Home Payments by accessing the CMS Home Payment Claim Form (PDF). The CMS Home Payments system will generate a claim number indicating that a Claim Form was successfully submitted and any additional information you need. The Claim Form will be sent by email to the claims' submission email address(s) and to the address you provided on the claim form.
What Is cms 1500?
The standard CMS 1500 Form or Health Insurance Claim is a document used by a non-institutional provider or supplier to bill Medical carriers and medical equipment in case a provider qualifies for a waiver from the Administrative Simplification Compliance Act requirement for electronic submission of claims. CMS 1500 Form may also be used for billing of Medicaid State Agencies.
For consistency with electronic transactions, the form aligns with the requirements of the Accredited Standard Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Reports Type 3 (TR3s).
The top half of 1500 Form is intended for the patient’s information when the bottom half has to be completed by the physician.
- Prpatient’s name, address, city, ZIP code, and contact number.
- Mark appropriate boxes.
- Add signature.
- The physician has to put the date of illness, injury etc.
- Indicate the provider’s name.
- Write additional claim information.
- Describe the diagnosis.
- Enter federal ID number, patient’s account number, and service facility location information.
- Specify the total charge as well as amount paid.
- Add signature.
You can submit the blank to a Medicare carrier, Durable Medical Equipment Medicare Administrative Contractor, or A/B MAC electronically using a device with software that meets online filing requirements established by the HIPAA claim and certain CMS requirements.
Contact your Medicaid State Agency for more details.
Online systems help you to organize your doc administration and boost the productiveness of your respective workflow. Comply with the quick handbook with the intention to complete Form CMS 1500 Claim, refrain from faults and furnish it in a timely manner:
How to finish a cms 1500 form?
- On the website along with the kind, simply click Start Now and pass towards editor.
- Use the clues to complete the applicable fields.
- Include your personal information and facts and contact information.
- Make positive that you just enter suitable knowledge and quantities in ideal fields.
- Carefully look at the content material of your form in addition as grammar and spelling.
- Refer that will help segment for those who have any doubts or deal with our Aid staff.
- Put an electronic signature on your own Form CMS 1500 Claim when using the guide of Sign Resource.
- Once the form is accomplished, push Finished.
- Distribute the ready sort by way of e-mail or fax, print it out or conserve in your system.
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