Where Is Condition Date On The 1500 Insurance Form

Required box 9 other insured s name.

Where is condition date on the 1500 insurance form. All items must be completed unless otherwise noted in these instructions. The cms 1500 form is the prescribed form for claims prepared and submitted by physicians or suppliers whether or not the claims are assigned. The form is used by physicians and allied health professionals to submit claims for medical services. Do not report icd 10 codes for claims with dates of service prior to october 1 2014.

Effective april 1 2019 horizon bcbsnj will change the way we process certain paper cms 1500 claim form submissions to align our processing approach with how we process electronic transaction submissions. Do not email fax or mail completed 1500 claim forms to the nucc. Due to the icd9 icd10 change services with dates prior to 10 01 2015 must be billed on separate claims from services with dates 10 01 2015 and later. Check the appropriate box for the patient s relationship to the insured when item 4 is completed.

1500 instruction manual changes. 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. For that reason here are some tips and a sample form to assist you. Cms 1500 form telephone number.

Beginning april 1 2019 paper cms 1500 claim submissions that include a date within fields 14 and 15 must also include an appropriate qualifier value as noted in the table in below to. The current version of the instructions for the 02 12 1500 claim form was released in july 2020. Item 6 patient s relationship to insured if medicare is primary leave blank. Printed in the upper left hand corner of your hcfa 1500 claim form are the name and.

The national uniform claim committee nucc changed the form cms 1500 and the revised form. Send completed forms to the appropriate payer. If the to date matches the from date the to date field may be left blank. Effective april 1 2014 medical assistance ma will only accept the revised cms 1500 form 02 12 version with icd 9 codes.

Version 8 0 7 20 1500 instruction manual. Enter the last name first name and middle initial of the enrollee in the other insurance policy 9a other insured s policy or group number 9b other insured s date of birth sex. Making sense of medicare paperwork including the hcfa 1500 claim form can be difficult. The nucc does not process claims.

Expiration date of 2020 03 31 pending o m b. Item 7 insurance primary to medicare insured s address and telephone number complete this item only when items 4 6 and 11 are. Please note that the lettered items on this page refer to letters printed on the sample form. Other insurance information blocks 9 9d this section is completed if the patient has other insurance.

Enter from and to dates of service in mmddyy format.