46 terms

Health Insurance Claim Form 1500

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CMS-1500
the universal claim form
When the Health Care Financing Administration (HCFA) became the centers for Medicare & Medicaid Services (CMS)
July 2001
HCFA means
Health Care Financing Administration
CMS means
Centers for Medicare & Medicaid Services
Who requires all physician to use the cms-1500 form when submitting claims for services provided
Medicare
Blocks 1 through 13
refers to patient information
Blocks 14 through 33
refers to physician information
A clearinghouse
Is an entity that receives transmissions from physicians' offices, separates the claims by carriers and performs software edit on each claim to check for errors.
Who paid a fee to the clearinghouse for their services
Physicians
After the check process is complete by the clearinghouse,the claim is sent to the proper
insurance carrier
block 1
medicare #, medicaid #, tricare o champus(sponsor ssn), champva (menber id#, group health plan(ssn or id#), Feca blk lung(ssn), other(ID)
block 1a
INSURED ID #
block 2
PATENT NAME(Last Name,First Name, Middle Initial)
block 3
PATIENT BIRTH DATE SEX
block 4
INSURED'S NAME (Last Name, First Name, Middle Initial)
block 5
PATIENT ADDRESS
block 6
PATIENT RELATION SHIP TO THE INSURED
block 7
INSURED'S ADDRESS
block 8
PATIENT STATUS
block 9 a-d
OTHER INSURED'S NAME
a.OTHER INSURED'S POLICY OR GROUP NUMBER
b.OTHER INSURED'S DATE OF BIRTH SEX
c.EMPLYER'S NAME OR SCHOOL NAME
d.INSURANCE PLAN NAME OR PROGRAM NAME
block 10
IS PATIENT CONDITION RELATED TO:
a.EMPLOIMENT?
b.AUTO ACCIDENT?
c.OTHER ACCIDENT?
block 10d
RESERVED FOR LOCAL USE
block 11
INSURED'S POLICY GROUP OR FECA NUMBER
block 11a-d
a.INSURED'S DATE OF BIRTH SEX
b.EMPLOYER'S NAME OR SCHOOL NAME
c.INSURANCE PLAN NAME OR PROGRAM NAME
d.IS THERE ANOTHER HEALTH BENEFIT PLAN?
if yes return to 9a-d
block 12
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE TO RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESARY TO PROCESS THIS CLAIM.I ALSO REQUEST PAYMENT OF GOVERMMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW
SIGNED____________ DATE___________
block 13
INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICES DESCRIBED BELOW
SIGNED_____________
block 14
DATE OF CURRENT ILLNESS (first symptom)OR
MM/DD/YY INJURY(accident)OR
PREGNANCY(LMP)
block 15
IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM/DD/YY
block 16
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
FROM MM/DD/YY TO MM/DD/YY
block 17
NAME OFREFERRING PROVIDER OR OTHER SOURCE
17a.
17b.NPI
block 18
HOSPITALITALIZATION DATES RELATED TO CURRENT SERVICES
FROM MM/DD/YY TO MM/DD/YY
block 19
RESRVED FOR LOCAL USE
block 20
OUTSIDE LAB? CHARGES
block 21
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.__._ 3.__._
2.__._ 4.__._
block 22
MEDICAID RESUMISION
CODE / ORIGINAL REF. NO.
block 23
PRIOR AUTHORIZATION NUMBER
block 24 A-J
A.DATE(S) OF SERVICE
FROM MM/DD/YY TO MM/DD/YY
B.PLACE OF SERVICE
C. EMG
D.PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circunstances)
CPT/HCPCS MODIFIER
E.DIAGNOSIS POINTER
F. $CHARGES
G.DAY OR UMITS
H.EPSOT FAMILY PLAN
I.
J.RENDERING PROVIDER ID#
block 25
FEDERAL TAX I.D. NUMBER SSN EIN
block 26
PATIENT ACCOUNT NO.
block 27
ACCEPT ASSIGMENT?
block 28
TOTAL CHARGE
block 29
AMOUNT PAID
block 30
BALANCE DUE
block 31
SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES CREDENTIALS (I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOFF)
SIGNED_______ DATE_______
block 32
SERVICE FACILITY LOCATION INFORMATION
a.
b.
block 33
BILLING PROVIDER INFO & PH ( )
a.
b.