Basic Red Health Insurance Form Hcfa Claim Form

All items must be completed unless otherwise noted in these instructions.

Basic red health insurance form hcfa claim form. Instructions for completing the cms 1500 claim form the center of medicaid and medicare services cms form 1500 must be used to bill sfhp for medical services. Use true black ink. Paper or electronic claim forms must be forwarded to the california. 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.

Do not use any other color ink such as blue purple or red. It is printed in red ink as shown on the right. If the user would like to complete the form online simply download click inside the box to begin and begin typing your information. Expiration date of 2020 03 31 pending o m b.

Approved omb 093b 1197 form cms 1500 06 15 omb no. The cms 1500 claim form is currently the only accepted form for submitting paper claims to both government and commercial health insurance carriers. The only forms accepted are the official forms printed in flint ocr red j6983 ink. Printed in the upper left hand corner of your hcfa 1500 claim form are the name and.

Do not use red ink to complete a cms 1500 claim form. Paper cms 1500 claim forms are processed by ocr optical character recognition to extract the claim details. Continue to use the current cms form 1500 02 12 beyond the o m b. Submit the scannable red ink version of the cms 1500 claim form.

The form is used by physicians and allied health professionals to submit claims for medical services. Use red pencils or red ink ballpoint pens. 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. For professional claims billing federal insurance medicare medicaid tricare the only acceptable paper claim forms are those printed in flint ocr red j6983 or an exact color match ink.

The health insurance claim form cms 1500 is used by allied health professionals physicians laboratories and pharmacies to bill for supplies and services provided to medi cal recipients. Avoid using old or worn ink cartridges toner cartridges or printer ribbons. Please note that the lettered items on this page refer to letters printed on the sample form. For that reason here are some tips and a sample form to assist you.