Cms 1500 Insurance Form

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

Cms 1500 insurance form. The center of medicaid and medicare services cms form 1500 must be used to bill sfhp for medical services. Expiration date of 2020 03 31 pending o m b. Claims must be made within 12 months after services are provided. Cms hhs websites cms global footer.

Download cms claim form 1500 which is used by health care professionals to bill medicare and medicaid. The form cms 1500 is the standard paper claim form health care professionals and suppliers use to bill medicare administrative contractors macs when a paper claim is allowed. A federal government website managed and paid for by the u s. See 42 cfr 411 24 a.

Claims may be electronically submitted to a medicare carrier durable medical equipment medicare administrative contractor dmemac or a b mac from a provider s office using a computer with software that meets electronic filing requirements as established by the hipaa claim standard and by meeting cms requirements contained in the provider enrollment certification category area of this web site and the edi enrollment page in. Centers for medicare medicaid services. Services cms designates the 1500 health insurance claim form as the cms 1500 02 12 and the form is. Professional paper claim form cms 1500 how to submit claims.

7500 security boulevard baltimore md 21244. Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. Simply type in the form fields. 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.

Continue to use the current cms form 1500 02 12 beyond the o m b. Health insurance common claims form. Approved omb 093b 1197 form cms 1500 06 15 omb no. Cms 1500 cms form number.

Insurance liability no fault worker s compensation or other insurance which is responsible to pay for the services for which the medicare claim is made. The cms 1500 pdf is ideal for submitting the standard paper claim to bill for services. If item 9 is completed the patient s signature authorizes release of the information to the health plan or agency shown. Cms 1500 claim form and ub 04 form instruction and guide cms 1500 claim form how to fill out correctly instruction for medical assistance processing the top right side of the cms 1500 must be blank.

The form is used by physicians and allied health professionals to submit claims for medical services.