Sample Health Insurance Form 1500 Filled Out

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.

Sample health insurance form 1500 filled out. Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. 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. Cms hhs websites cms global footer. Boxes 1 3 and 5.

It provides information about the client their corresponding insurance policy. Tufts does not want the new form until april 1 2014. 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. Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es.

For medical assistance processing the top right side of the cms 1500 must be blank. All insurance companies use a standardized form called the cms 1500 which is printed in red ink. Centers for medicare medicaid services. A federal government website managed and paid for by the u s.

This is pretty straightforward demographic information on your client. Health insurance common claims form. The cms 1500 form is the health insurance claim form used for submitting physician and professional claims for providers. The form is used by physicians and allied health professionals to submit claims for medical services.

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. 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. Information and instructions for form cms 1500 02 12 for all insurance companies. 7500 security boulevard baltimore md 21244.

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. Instructions on how to fill out the cms 1500 form item instructions item 1 type of health insurance coverage applicable to the claim show the type of health insurance coverage applicable to this claim by checking the appropriate box e g if a medicare claim is being filed check the medicare box. Cms 1500 cms form number. All items must be completed unless otherwise noted in these instructions.

Item 1a insured s id number. 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.