Health Insurance Claim Form 1500 Example

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

Health insurance claim form 1500 example. The cms 1500 form is the health insurance claim form used for submitting physician and professional claims for providers. 7500 security boulevard baltimore md 21244. For example it may be. Sample cms 1500 claim form rt or 50 to denote the specific knee injected or a bilateral injection.

Health insurance common claims form. Approved omb 093b 1197 form cms 1500 06 15 omb no. Continue to use the current cms form 1500 02 12 beyond the o m b. Tufts does not want the new form until april 1 2014.

A federal government website managed and paid for by the u s. Centers for medicare medicaid services. Download cms claim form 1500 which is used by health care professionals to bill medicare and medicaid. 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.

Expiration date of 2020 03 31 pending o m b. List the hcpcs code j7322 to represent the injection. If an emergency code is listed in the unshaded area place the delay reason code in the shaded area. 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.

All items must be completed unless otherwise noted in these instructions. When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility the cms 1500 form would be used to bill for their services. 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. 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.

Cms 1500 delay reason code claim example for the cms 1500 form enter a delay reason code in the unshaded area of the emg field box 24c when the claim is beyond the six month billing limit. Claims must be made within 12 months after services are provided.