Medical Insurance Form 1500

Download cms claim form 1500which is used by health care professionals to bill medicare and medicaid.

Medical insurance form 1500. The cms 1500 claim form dated 08 05 replaced the outdated hcfa 1500 health insurance claim form dated 12 90. If the user would like to complete the form online simply download click inside the box to begin and begin typing your information. All items must be completed unless otherwise noted in these instructions. The form is used by physicians and allied health professionals to submit claims for medical services.

The cms 1500 form is the standard paper claim form used by a non institutional provider or supplier to bill medicare carriers and medicare administrative contractors macs when a provider qualifies for a waiver from the administrative simplification compliance act asca requirement for electronic submission of claims. There are several vendors who sell the cms 1500 claim form in various configurations such as single sheet continuous feed laser etc. Download the fillable hcfa 1500 claim form that is both a fillable and or printable medical claim form that will provide insurance illness and injury information for medical services claims. 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.

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. 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 compensation program act of 2000 eeoicpa. 7500 security boulevard baltimore md 21244.

One of the biggest changes for the cms 1500 is the addition of the npi field. A federal government website managed and paid for by the u s. Expiration date of 2020 03 31 pending o m b. In addition to medicare parts a b and for medicare durable medical equipment administrative contractors.

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.