Sample Health Insurance Form 1500 Behavioral Health

Mental health cms1500 form download jpg pdf here s a copy of the pdf form for your download.

Sample health insurance form 1500 behavioral health. The form is used by physicians and allied health professionals to submit claims for medical services. Patient status single feca blk lung requiredfieids la. Health insurance claim form 1. Insurance plan name or program name r enter the subscriber s insurance plan name include name of state i e blue shield of nm.

Tips for completing the cms 1500 version 02 12 claim form failure to provide valid information matching the insured s id card could result in a rejection of your claim. Patient s or authorized person s signature i authorize the release of any medical or other information necessary to process this claim. Number cloo pica for program in item i pica 1. 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.

The mental health division provides an array of opportunities for partners to work together in the spirit of hope toward recovery. Is there another health insurance benefit plan r select whether there is another health insurance plan. Medicare medicaid medicaid medicare tricare champus champva. Expiration date of 2020 03 31 pending o m b.

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. Our mental health insurance billing staff is on call monday friday 8am 6pm to ensure your claims are submitted and. Remember if there is another health insurance plan you will need to complete fields 9 9a and 9d. Eap billing form 1500 health insurance claim form approved by national uniform claim committee 08 05 group health plan patient s birth date self 8.

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. Information and instructions for form cms 1500 02 12 for all insurance companies. All with the goal of making the professional side of behavioral health a little easier faster and less expensive.

Continue to use the current cms form 1500 02 12 beyond the o m b. 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.