Also known as the Healthcare Financing Administration (HCFA) form, the CMS-1500 form is used for claim reimbursement for several government insurance plans such as Medicaid, Tricare, and Medicare. Insured’s name is required to be entered here. Prior Authorization Number: Box 23 The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows: 1. INSURED’S I.D. You need to enter the diagnosis code from box 21. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code. The CMS HCFA-1500 form is the standard paper claim form used by a non-institutional provider or supplier to bill Medicare carriers and Medicare administrative contractors (MACs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. This field requires the insured’s policy or group number to be filled. Insured’s ID Number – This box requires the Medicare ID of the patient indicating whether Medicare is the primary payer or the secondary payer. You are required to enter the applicable state and country sales tax if the item is a taxable medical supply. Box 14: This field asks you to enter the date of current illness or injury or pregnancy (last menstrual period – LMP). CMS 1500 Form Item Instructions Item 1 Type of Health Insurance Coverage Applicable to the Claim Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box. The form is used by Physicians and Allied Health Professionals to submit claims for medical services. The street address, area, state, ZIP code, and telephone number are included. It also has one box which needs to be checked indicating the gender of the patient. An independent laboratory must join a diagnosis only for procedures with restricted scope. However the CMS pickup truck from the U. H. Centers intended for Medicare health insurance and Medical preparing Services mainlined the Medical Claim Form 1500, the field of Medical Claim h billers (MIBs) is complete of business and authorities Plus, as you hear regarding a deal to file the federal and state fees for totally free with 1040 variety variants (H or perhaps curiosity (less than $1, 500). Box 24F: It holds the total billed amount for each service line.  You need to enter the charge for services in the dollar amount format. BOX 33B: The ID qualifier and PIN of the billing provider are required to be entered in this box. Note: Do not include decimals. You are required to enter the applicable state and country sales tax if the item is a taxable medical supply. You need to enter the diagnosis code from box 21. Having understood the purpose of the popular health or medical insurance claim form, let’s now understand it in detail. It won’t be required unless you are billing for an infant using the mother’s ID. © COPYRIGHT-2021 CAPLINE SERVICES. Note: If services are rendered in the patient’s home or facility, enter the service location of the provider’s main office. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. It’s a mandatory field. In the field’s shaded area, enter the non-NPI ID number. If you’re applying for a benefit on someone’s behalf, you may need to ask their doctor for a DS1500 report. You must fill the code number and code of an ICD-9-CM diagnosis with greatest accuracy. There are other “not required” and “if applicable” fields in the form. Pages. Box 4 (if applicable): Insured’s name is required to be entered here. Suite 430 Houston, TX. Item number Required Field? You can fill them as per your eligibility/requirement. The form fields, headings, and lines are rendered invisible to the scanner by use of what is commonly called "drop out" ink. Box 24A: This box requires the date for each operation, service, or supply to be entered in the six or eight digit format: MM/DD/YY or MMDDCCYY. For example, if you have filed a Medicaid claim, you would need to check the Medicaid checkbox. The street address, area, state, ZIP code, and telephone number are included. It won’t be required unless you are billing for an infant using the mother’s ID. The non-institutional providers and suppliers who can use the CMS-1500 form to bill medical claims include Ambulance services, Clinical social workers, Physicians and their assistants, Nurses including clinical nurse specialists and practitioners, Psychologists, etc. CMS 1500 Claim Forms "NEW" HCFA (Version 02/12) - Health Insurance, Laser Cut Sheet: Satisfy the NEW medical billing requirements with compliant CMS-1500 forms. The CMS 1500 is the red ink on white signNow standard claim form used by physicians and suppliers for claim billing. BOX 1: It’s optional. The street address, area, state, ZIP code, and telephone number are included. The CMS 1500 claim form uses a unique ink that allows the form to be scanned quickly and because of that, the blank CMS 1500 form cannot be handwritten or printed by you. Modifiers, when applicable, are listed to the right of the primary code under the column marked “modifier”. Enter in priority order, up to 4 codes (primary, secondary condition). Claim Identification Number: Box 1a 2. This form is used by … Box 5: This box requires you to enter the patient’s address and telephone number. Box 24B: This field asks you to enter the location where the service was rendered. Please contact your State Agency for more details on Medicaid billing. If the user prefers to hand-write the information, print the form and fill it out by … The type of insurance needs to be entered here. Enter the patient’s name as mentioned on the ID card. Some of the options you would get in the form are Medicare, Medicaid, TRICARE, CHAMPVA, FECA, Black Lung, Public Health Insurance, etc. This document is intended to be a guide for completing the 1500 Claim Form and … INSURED’S NAME (Last Name, First Name, Middle Initial) 7. This field requires you to enter the insured’s address. The CMS-1500 form, also known as the Healthcare Financing Administration (HCFA), and the Professional Paper Claim Form, is used for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare.Although it was developed by The Centers for Medicare and Medicaid (CMS), it has become the standard form used … Buy Now. Instructions and guideline for CMS 1500 claim form and UB 04 form. Enter the patient’s name as mentioned on the ID card. $179.95 for Windows. Box 24J: The person who rendered the service is mentioned in this box. INSURED’S ADDRESS (No., Street) 11. This field asks you to enter the date of current illness or injury or pregnancy (last menstrual period – LMP). The form is usually not hospital-focused. The CMS-1500 Form (Health Insurance Claim Form) is sometimes referred to as the AMA (American Medical Association) form. Enter the diagnosis code and the primary reason for providing the services. Description and Instructions N/A Situational When submitting a Medicare Replacement Plan claim, write or stamp “Medicare Replacement Plan” in the left top margin of the claim. Box 24 E: This field is for indicating the Diagnosis Code. You must fill the code number and code of an ICD-9-CM diagnosis with greatest accuracy. There are 33 boxes in a CMS-1500 form. Box 31: This field demands the signature of the physician or supplier along with the date. Only the information entered by the user will print out. Note: Do not include decimals. Insert the NPI number in the field’s unshaded location. It holds the total billed amount for each service line.  You need to enter the charge for services in the dollar amount format. If a replacement provider has been used, enter the details of that provider here. APPROVED OMB-0938-0999 FORM CMS-1500 (08-05) BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. You need to enter the NPI of the provider. If the payer requires Box 32, s/he needs to ensure that the addresses are slightly different. You need to enter the appropriate two-digit code as listed in Place of Service Codes for Professional Claims. Read the instructions and tips below first. Some of the options you would get in the form are Medicare, Medicaid, TRICARE, CHAMPVA, FECA, Black Lung, Public Health Insurance, etc. 1 Not Required Check “Medicaid” when billi Paper claims submitted to Medicare are electronically read using Optical Character Recognition (OCR) equipment. The Rendering Provider is the individual or firm (laboratory or another facility) that made or managed the treatment. Enter the details in the format below: Box 33A: You need to enter the NPI of the provider. 33a A Enter the 10-digit NPI number of the billing provider. The 1500 Health Insurance Claim Form (1500 Claim Form) is in the public domain. Download CMS Claim Form 1500 which is used by health care professionals to bill Medicare and Medicaid. All of these boxes must be filled for the insurance claim to pass through. Box 25: The form asks you to enter the Federal tax ID number in this box. The form asks you to enter the Federal tax ID number in this box. CMS-1500 Professional. What is an Aging Report in Medical Billing, CMS-1500 Form in Medical Billing: Purpose and Explanation, How COVID-19 has impacted the Medical Billing and Healthcare Industry, What is Double Billing in Medical Billing, What is Cash Flow Cycle in Medical Billing. Do not leave blank as units should at least be 1. NUMBER. Insurance Plan Name: Box 11c 4. CMS 1500 Form also known as HCFA 1500 and has 33 blocks. FREE FILLABLE CMS medical claim FORM 1500 template with instructions Manual, FREE CMS-1500 (HCFA) CLAIM FORM TEMPLATE PDF. The CMS-1500 form is the standard paper claim form used by a non-institutional provider or supplier to bill Medicare carriers and Medicare administrative contractors (MACs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. * CMS-1500 (version 02/12) replaces form (version 08/05). The form is a factual report about your condition and symptoms. FormDocs CMS-1500 claim form software is an affordable and easy to use solution for filling and submitting CMS 1500 insurance and Medicare claim forms for your regular services as well as for adjunct COVID-19 testing and COVID-19 vaccination services. Patient and Insurance Information Every medical claim is a legal document. Injury Date: Box 14 2. Making sense of Medicare paperwork, including the HCFA 1500 claim form, can be difficult. Please contact … You … 77032. The required field wants you to enter procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. This section requires applicable CPT/HCPCS National codes. If the user would like to complete the form online, simply download, click inside the box to begin and begin typing your information. Box 7: This field requires you to enter the insured’s address. CMS-1500 Lite. If you use the CMS 1500 claim form - whether the paper form or a data-entry version in your practice management system - now's the time to make sure you have the latest version, announced in the summer. Fillable 1500 Health Inusrance Claim Form. This box requires you to enter the patient’s relationship with the insured. Item 1a Insured’s ID Number (Patient’s Medicare Health Insurance Claim Number - HICN) This is a required field. BOX 1A: Insured’s ID Number – This box requires the Medicare ID of the patient indicating whether Medicare is the primary payer or the secondary payer. Box 33 is used to signify the Billing Provider’s name, address, ZIP code, and telephone number. 1a. Enter the name, first name, and middle initial of the patient, if any, as seen on the Medicare Card of the patient. Â. where an 8-digit birth date (MM/DD/YYYY) of the patient is required to be filled. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800. This field demands the signature of the physician or supplier along with the date. How to fill box 33 on CMS 1500 33 Billing Provider Info & Ph.# A/A& M/M Enter the billing provider’s name, address, and telephone number Do not use slashes, hyphens, or spaces. In the ICD Indicator section of this box, you must enter the ICD-10 diagnosis indicator of 0 to avoid a claim denial. Box 24D: This section requires applicable CPT/HCPCS National codes. The NUCC has developed this general instructions document for completing the 1500Claim Form. Therefore, the A merican Medical Association (AMA) embraced an assignment in the 1980s to work w ith the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA), and many other payer organizations through a group called the Uniform Claim Form Task Force to standardize and promote the use of a universal health claim form. Enter the diagnosis code and the primary reason for providing the services. You would need to enter the NPI of the facility. As a medical billing company for various doctors and facilities, we understand that knowing which form to use is the first step to filing a successful claim. Box 2: It’s a mandatory field. © 2008-2021 MDWizards.com. In simple words, this form is used to bill for medical services provided to patients who are covered under insurance. The ID qualifier and PIN of the billing provider are required to be entered in this box. It is printed in red ink as shown on the right. S… Although it was developed by The Centers for Medicare and Medicaid (CMS), it has become the standard form used by all insurance carriers. The form is also used to bill Medicaid State Agencies. You cannot leave this field blank. 4. The CMS-1500 form is the standard paper claim form used by a non-institutional provider or supplier to bill Medicare carriers and Medicare administrative contractors (MACs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. For that reason, here are some tips and a sample form to assist you. Tips and updates. Class # 6 "Understanding the CMS 1500 Form". Please note that the lettered items on this page refer to letters printed on the sample form. A DS1500 form describes your illness and treatments. The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It also has one box which needs to be checked indicating the gender of the patient. The HCFA 1500 claim form, also known as CMS-1500, enables medical facilities to submit health insurance claims to insurance carriers such as Medicare and Medicaid; this form … This box requires you to enter the patient’s address and telephone number. Box 11 D: Check Yes or No if there is any other health benefit plan. A. Only ‘self’ or ‘child’ is applicable. Box 11: This field requires the insured’s policy or group number to be filled. Please enter the number of medical visits, units of anesthesia time, amount of oxygen, etc. For example, if you have filed a Medicaid claim, you would need to check the Medicaid checkbox. Box 6: This box requires you to enter the patient’s relationship with the insured. Please enter the number of medical visits, units of anesthesia time, amount of oxygen, etc. CMS 1500: The billing form used by the Center for Medicare Services (CMS) for all claims made by physicians and other providers of health care services. INSURED’S POLICY GROUP OR FECA NUMBER. The right-side margin of the CMS-1500 claim form has a note printed sideways that says carrier with arrows that indicate the top margin. Using re-submission codes (HCFA 1500 claim form: Box 22) This article will walk you through the process of editing a claim to show a specific re-submission code in Box 22 before refiling. Box 32: This field requires the name and address of the facility where services were rendered. The default setting for Box 22 on the HCFA 1500 form is "1-Original." payment of the claim. The Rendering Provider is the individual or firm (laboratory or another facility) that made or managed the treatment. The office will remove that from the EDI file “if” Box 32 has the same information as Box 33. Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES' COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT of 2000 (EEOICPA) To submit the CMS 1500 form correctly you first must purchase them online. Only ‘self’ or ‘child’ is applicable. If you send a CMS 1500 claim form that you did not purchase, but printed yourself, it will be denied. The numeral ‘1’ must be entered if only one operation is conducted.  Do not enter a decimal point or leading zeroes. All items must be completed unless otherwise noted in these instructions. The current version of the original manual from the National Uniform Claim Comettee of how to complete the CMS1500 claim form. Box 3: It is where an 8-digit birth date (MM/DD/YYYY) of the patient is required to be filled. UB-40 and CMS-1500 are the two most common claim forms for submitting to insurance companies. The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. 3838 N Sam Houston Pkwy E. In the ICD Indicator section of this box, you must enter the ICD-10 diagnosis indicator of 0 to avoid a claim denial. Also known as the Healthcare Financing Administration (HCFA) form, the CMS-1500 form is used for claim reimbursement for several government insurance plans such as Medicaid, Tricare, and Medicare. The type of insurance needs to be entered here. This box requires the details of the diagnosis or the nature of the illness of the patient. Health insurance claim form 1500 1a. An independent laboratory must join a diagnosis only for procedures with restricted scope. ​When you create a claim for a patient, you can enter all the relevant details for that patient and their claim: The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows: 1. In this field, please enter the total bill for all services in dollars and cents. You cannot leave this field blank. Beginning April 1, payers no longer will accept the older version of the form … Free Trial. Box 21: This box requires the details of the diagnosis or the nature of the illness of the patient. The "static" form fileds are visible on the screen only. Buy Now. Buy Now. The only forms accepted are the "official" forms printed in Flint OCR Red (J6983) ink. They will not print over your original CMS-1500 sheet. When the dates ‘’from’’ and “to” for a set of equivalent services are displayed, insert the number of days or units in column G; record only a range per month, do not combine months in a list. $69.95 for Windows. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. Modifiers, when applicable, are listed to the right of the primary code under the column marked “modifier”. The required field wants you to enter procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. Box 28: In this field, please enter the total bill for all services in dollars and cents. It is also known as a DS1500 medical condition report. In addition to Medicare parts A/B and for Medicare durable medical equipment Administrative Contractors. Printed in the upper left-hand corner of your HCFA 1500 claim form are the name and address of your supplemental insurance company. Section 1128B of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. It’s optional. All rights reserved. CMS-1500 Standard. Do not leave blank as units should at least be 1. Box 24G: This field requires the number of days or units. The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code. * Required for healthcare providers to bill a patient's insurance company for reimbursement of medical claims. This scanning technology allows for the data content on the form to be read and transferred into a format for automated processing by Medicare systems. The numeral ‘1’ must be entered if only one operation is conducted.  Do not enter a decimal point or leading zeroes. ALL RIGHTS RESERVED. The street address, area, state, ZIP code, and telephone number are included. Failure to provide medical information under FECA could be deemed an obstruction. The CMS-1500 form, popularly known as the Professional Paper Claim Form, is a medical claim form that can be used by non-institutional providers and suppliers to bill claims. This field requires the number of days or units. The CMS 1500 claim form is currently the only accepted form for submitting paper claims to both government and commercial health insurance carriers. This field is for indicating the Diagnosis Code. Free Trial. Buy now or try risk-free for 30-days. Compare and choose the solution that's best for you. If a replacement provider has been used, enter the details of that provider here. In the field’s shaded area, enter the non-NPI ID number. Policy Number: Box 11 3. The CMS-1500 Form is the prescribed form for claims prepared and submitted by physicians or suppliers, whether or not the claims are assigned. Note: stamps or initials are not accepted. They are for easy orientation while you are entering your medical claim. The top half of the CMS-1500 medical claim form is used to report patient demographic and medical plan billing information. Insert the NPI number in the field’s unshaded location. FormDocs Fillable CMS Form 1500 Insurance Claim Medical Billing Software Editions. NUMBER (For Program in Item 1) 4. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or mislea ding information may be guilty of a criminal … Claim Form Billing Instructions: CMS-1500 Claim Form . In simple words, this form is used to bill for medical services … However, some insurance companies accept the black and white photocopy of the form. This statement is called a DS1500 form. The form is also used to bill Medicaid State Agencies. Enter the name, first name, and middle initial of the patient, if any, as seen on the Medicare Card of the patient. Â. The person who rendered the service is mentioned in this box. You should be aware that P.L. Note: The article includes all the required fields in the CMS-1500 form. HCFA 1500 and UB 92 form instruction. Box 33: This box is divided into three sub-boxes: 33, 33A, and 33B. The accountability of the design and maintenance of the CMS-1500 form rests with the National Union Claim Committee (NUCC). Claims must be made within 12 months after services are provided. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Let’s take a look at all the boxes or fields step by step. Free Trial . $129.95 for Windows. It is advisable to submit the original red and white version of the form. As per the latest updates, the NUCC has released the annual, updated version of the reference instruction manual of the CMS-1500 form. INSURED’S I.D. Download the Fillable HCFA 1500 Claim Form that is both a fillable and/or printable medical claim form that will provide insurance, illness and injury information for medical services claims. When billing for HMO Copay, write or stamp “HMO Copay Due” in the left top margin. Enter in priority order, up to 4 codes (primary, secondary condition).