How To Fill Out Health Insurance Claim Form 1500

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

How to fill out health insurance claim form 1500. 7500 security boulevard baltimore md 21244. How to complete a health insurance claim form 1500. 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. If either of these cases apply to you you will need to print out a health insurance claim form fill in all of the necessary details enclose the required documentation and then send it off via the postal service.

Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es. Add an e signature by typing or drawing with your touchpad. Approved omb 093b 1197 form cms 1500 06 15 omb no. Enter the 10 digit clinical laboratory improvement act clia certification number for laboratory services billed by an entity performing clia covered procedures.

Enter the zip code for the point of pickup for ambulance claims. You may also upload your signature from your device. For medical assistance processing the top right side of the cms 1500 must be blank. Reviewed on february 26 2017 0 reviews.

Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. Instructions on how to fill out the cms 1500 form. Tips for completing the cms 1500 version 02 12 claim form page 1 of 12 enter in the white open carrier area the name and address of the payer to whom this claim is being sent. According to very well health the cms 1500 is the red ink on white paper standard claim form used by physicians and suppliers for claim billing.

The form is used by physicians and allied health professionals to submit claims for medical services. 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. A federal government website managed and paid for by the u s. 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.