Insurance Form 1500 Example

Any obstructions in this area will hinder timely and accurate processing of claims.

Insurance form 1500 example. Insured s policy group or feca number a. Insured s name last name first name middle initial 7. The top right margin of the claim form should not. Do not use the upper right margin of the claim form.

Expiration date of 2020 03 31 pending o m b. Number for program in item 1 4. All items must be completed unless otherwise noted in these instructions. The cms 1500 form is the health insurance claim form used for submitting physician and professional claims for providers.

Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. Claims must be made within 12 months after services are provided. The contractor uses it. Approved omb 0938 1197 form 1500 02 12 1a.

Information and instructions for form cms 1500 02 12 for all insurance companies. Download cms claim form 1500 which is used by health care professionals to bill medicare and medicaid. 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. Tufts does not want the new form until april 1 2014.

To look at it a little more closely and put it in layman s terms therabill tells us the cms hcfa 1500 form is the standard paper claim form used to bill an insurance for rendered services and supplies. Insured s address no street city state zip code telephone include area code 11. For medical assistance processing the top right side of the cms 1500 must be blank. Completion of the cms 1500 02 12 claim form.

In short it is a health insurance claim form cms 1500. Insured s date of birth b. The cms 1500 form health insurance claim form is sometimes referred to as the ama american medical association form. 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.

It provides information about the client their corresponding insurance policy. Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es. 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. Continue to use the current cms form 1500 02 12 beyond the o m b.

In addition to medicare parts a b and for medicare durable medical equipment administrative contractors.