You can Download a pdf version of the HCFA Claim Form, and also a 35-page instruction book for filling out the form. You can download the Acrobat Reader, if you do not already have it, free from Adobe.
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FREE HCFA/CMS 1500 FORM TEMPLATE for medical claims in fillable format: The CMS HCFA-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. This is a Cms 1500 download page. You can free download Cms 1500 to fill, edit and print.
Otherwise, here is an abridged version of instructions to fill out the HCFA 1500 Claim Form:
Patient Information (blocks 2-8). REQUIRED
Box 2 - Last Name, First Name, Middle Initial (if any)
Box 3 - Date of Birth and Sex
Box 4 - Medi-Cal Beneficiary Name (if different than the name in block 2)
Box 5 - Patient's Address
Box 6 - Patient's Relationship to Insured (used in conjunction with information on block 9)
Box 7 - Insured Address (used in conjunction with information on block 9)
Box 8 - Patient's Marital and Work Status
Other insurance information (blocks 9-9d) - This section is completed if the Patient has other insurance. Macos mojave preview app. REQUIRED
Box 9 - Other Insured's Name. 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
9c - Other Insured's Employer's Name
9d - Insurance Plan Name or Program Name
Please see under Section X, Claims Processing and Payment, Coordination of Benefits, for more information. SFMHP is the payor of last resort; therefore, claims for patients who are covered under Medi-Cal and another insurance plan must include a copy of the insurance Explanation of Benefits or Claim Denial Letter in order for SFMHP to determine payment liability. Medicare/Medi-Cal crossover claims are sent to the State's fiscal intermediary (EDS) or the Medicare fiscal intermediary. They are not processed by the SFMHP Claims Unit.
Patient's Condition (blocks 10a-c) - Is the Patient's condition related to Employment? Auto Accident? Other Accident? REQUIRED
Check 'YES' or 'NO' to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Item 24. Any item checked 'YES' indicates there may be other insurance primary to MediCal. Identify primary insurance information on Item 11.
Enter the State postal code (i.e.: CA for California)
Patient Signatures (blocks 12-13) REQUIRED
Box 12 - Release of Information: Patient's or Authorized Person's Signature
Box 13 - Assignment of Benefit: Insured or Authorized Person's Signature
Comments (block 19)
Free-form 'comments' field to insert additional claim information not designated to appear in another block.Diagnosis Coding (block 21) REQUIRED
Enter the patient's DSM IV diagnosis.
No narrative information is needed in block 21.
Document the condition(s) to the highest degree of specificity.
Book of ryan download torrent. Prior Authorization Number (block 23) REQUIRED
Record the Authorization number issued by the ACCESS Team for the services being claimed.
Dates of Service (block 24A) REQUIRED
Enter the month, day, and year for each procedure or service. When 'from' and 'to' dates are shown for a series of identical services, enter the number of days or units in block 24d. If the 'from' and 'to' dates of services are the same, code only the 'from date' of service using the appropriate six-digit format (e,g,: 010197)
Do not date range services in different months on one detail line. Instead, you must split up the dates, prorating the charges and quantity billed appropriately.
Place of Service (block 24B) REQUIRED
Enter the appropriate place of service code (list follows these instructions). Make sure that the procedure code you are using matches the place of service. For example, do not bill 99220 (Hospital Observation Care:Initial Problem = High) with a place of service code 11 (Office). List the name and address of the facility where service was rendered on block 32.
Use the 2 digit code only - do not use abbreviations such as 'O' for Office, etc.
Procedure Code (block 24d) REQUIRED
Enter the authorized HCPCS (HCFA Common Procedure Coding System) codes listed in the authorization letter.
Diagnosis Pointer (block 24E) REQUIRED
Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the appropriate diagnosis.
Do not use DSM IV codes in this block. Use only the reference number(s) from block 21.
$ Charges (block 24F) REQUIRED
Enter the charge for each item.
Days or Units of Service (block 24G) REQUIRED
Enter the number of days or units. When multiple services are provided, enter the actual number provided.
EPSDT Service (block 24H)
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Check if the service being claimed is an EPSDT procedure.
COB - Coordination of Benefits (block 24J)
Check if the service is covered by another insurance carrier. Please attach an Explanation of Benefits form showing this service was claimed to the other carrier. Note other health coverage information in blocks 9 a-d, 6, and 7.
Federal Tax ID Number (block 25) https://sitehair235.weebly.com/blog/slideshow-software-for-mac-2015.
Enter Physician's Social Security Number (check SSN box) or Tax ID Number. If a Group Practice, enter the Employer Identification Number (EIN)
Total Charge (block 28)
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Enter the total amount of the services you are claiming.
Amount Paid (block 29) REQUIRED
Enter any co-payment amounts paid to you by the Patient or their responsible party during the period covered by your claim.
Balance Due (block 30)
Enter the amount due to you for this claim. Please note, the actual claim payment is subject to SFMHP Published Rate Schedule, coordination of benefits policies, and the service amount(s) listed on the authorization; and, is limited to the unpaid balance of the Provider's charge.
Signature of Physician or Supplier (block 31) REQUIRED
Sign and record the date you are submitting the claim. The signature represents the provider's certification that all information on the document is true and accurate.
Name and Address of Facility where services were rendered, if other than Practitioner's Office. (block 32) REQUIRED
Enter the name and address of the facility if the services were furnished in a hospital, clinic, patient's home, or facility other than the physicians' office. If the practitioner's address listed on block 33 and the place of service is the same, please write 'SAME'.
This block must be completed whether the provider performs the work at the office or at another location.
Provider Billing Information (block 33) REQUIRED
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Enter the name, address, zip code and telephone number of the practitioner or provider group billing for the service. Enter under 'PIN#' your SFMHP Provider ID Number.
Fillable Hcfa 1500 Form
1500 Claim Form 02/12 Version
Use of the Version 02/12 1500 Claim Form went into effect April 1, 2014.
The following is the PDF of the revised 1500 form, including the template and grid versions: (The form image may not print to scale. This image of the form should not be used for claims submission. This image should also not be used by forms printers to create the form.)
• 02/12 Claim Form
• 02/12 Claim Form
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DO NOT email, fax, or mail completed 1500 Claim Forms to the NUCC. The NUCC does not process claims. Send completed forms to the appropriate payer.
To receive copies of the 02/12 1500 Claim Form, contact:
• Your current forms supplier;
• TFP Data Systems: This email address is being protected from spambots. You need JavaScript enabled to view it. or 800-482-9367 ext. 58029; or
• The Government Printing Office: http://bookstore.gpo.gov/catalog/government-forms-phone-directories or 866-512-1800
• TFP Data Systems: This email address is being protected from spambots. You need JavaScript enabled to view it. or 800-482-9367 ext. 58029; or
• The Government Printing Office: http://bookstore.gpo.gov/catalog/government-forms-phone-directories or 866-512-1800
Free Hcfa 1500 Form Download
02/12 1500 Form Change Log
The following change log shows all changes between the 08/05 version and 02/12 version of the form.
Blank Hcfa 1500 Form free download. software
• 02/12 1500 Form Change Log
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1500 Claim Form Change Requests
To request changes to the 1500 Claim Form layout, please fill out the form below and email it to This email address is being protected from spambots. You need JavaScript enabled to view it.. The same form can be used to submit requests for changes to the NUCC 1500 Reference Instruction Manual.
• 1500 Form Change Request Form
Free Hcfa 1500 Form Printable
Background Information
Blank Hcfa 1500 Form Free Download 02/12
The NUCC replaced the Uniform Claim Form Task Force, which was co-chaired by the AMA and CMS and resulted in the development of the 1500 Claim Form, a single paper claim form for use by all third-party payers. With the transition of the medical community to electronic data interchange and the proliferation of data element definitions among various payers, it became essential that an organization be established to maintain uniformity and standardization in these areas. The NUCC is responsible for maintaining the integrity of the data sets and physical layout of the hard copy 1500 Claim Form.
From the provider viewpoint, non-uniform data elements have caused significant frustration, claims billing and processing delays, and rejections. From the payer viewpoint, claims that are not in the required format may be resubmitted several times before they can be processed. Minecraft 1.8 1 mac cracked free download. The result is a very labor-intensive and costly business practice for providers and payers.
Through an iterative process, the NUCC used existing implementation guides, data dictionaries and results from ongoing standardization efforts within the health care industry to consolidate the many current data sets into one set. The NUCC continues to work to optimize, as necessary, coordination of implementation within the health care industry, working with ASC X12N as required, to resolve data maintenance and standards problems that arise from the NUCC's work.