Hcfa 1500 Health Insurance Claim Form Example

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.

Hcfa 1500 health insurance claim form example. Services cms designates the 1500 health insurance claim form as the cms 1500 02 12 and the form is referred to throughout this fact sheet as the cms 1500. Until march 31 2014 one can use either the old cms 1500 claim form version 08 05 as marked in the lower right hand corner or the new cms 1500 version 02 12 for paper claims submitted to medicare bcbs and bhs. Item 1a insured s id number patient s medicare health insurance claim number. Printed in the upper left hand corner of your hcfa 1500 claim form are the name and.

Continue to use the current cms form 1500 02 12 beyond the o m b. Expiration date of 2020 03 31 pending o m b. The form is used by physicians and allied health professionals to submit claims for medical services. In essence it is a claims form that the medical professional or the medical office completes and submits to the health insurance company.

All items must be completed unless otherwise noted in these instructions. Although it was developed by the centers for medicare and medicaid cms it has become the standard form used by all insurance carriers in short it is a health insurance claim form cms 1500. This billing guide is designed to assist with the completion of the cms 1500 claim form. Submit only the red drop out approved cms 1500 02 12 claim form.

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. In addition to billing medicare the 837p and form cms 1500 may be suitable for billing various government and some private insurers. An hcfa 1500 form is used to document a medical procedure.

Making sense of medicare paperwork including the hcfa 1500 claim form can be difficult. Authorizes any entity to release to medicare medical and nonmedical information including employment status and whether the person has employer group health 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. Tufts does not want the new form until april 1 2014. 1500 health insurance claim form reference instruction manual v 02 12 updated july 2019.

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.