Hcfa 1500 Claim Form Free Download

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.

Tips for Filling the Template

It is very important to ensure the information is accuracy and exactness when you are filling the health insurance claim form 1500. What's more, to ensure the completeness of the form, it is also important to make sure that all fields are duly filled. Considering the novelty and diversity of the CMS 1500, filling out such a form can be quite daunting, especially for those who are not familiar with the field. The following tips will help you fill out CMS 1500 successfully and accurately:

Always use Pica or Arial fonts to fill out these forms. The font size is between 10 and 12.

Fill the form with capital letters and always use black ink or black fonts.

Do not use italics or broken characters, dot matrix fonts, stylized fonts, or red ink when filling out the CMS 1500 form.

Make sure that the data you enter is in the middle of the box and the edges does not be touched.

Use standard codes in various fields and never use any narrative text.

Hcfa 1500 Claim Form Free Download 2016

Remember that the size of the form you submitted is 81⁄2' x 11'. So, ensure to remove all the perforations. Also, it is important to make sure that all other attachments to the form are smaller than the size of the form.

Never use stickers or rubber stamps and your name and address on forms.

Do not fill in any special characters on the form, such as hyphens, periods, same marks, dollar signs, etc.

Make sure you submit the original form and keep a photocopy for your reference. Any uncommitted forms will not be processed.

What Is a CMS 1500 Form

Developed by the National Uniform Claim Committee (NUCC), the CMS-1500 form is a standard claim form, that is used by all of the non-institutional medical providers or suppliers to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider meets the requirments from the Administrative Simplification Compliance Act (ASCA) for a waiver for electronic submission of medical claim form 1500. It is also used for the billing of some Medicaid agencies (more details you can contact your Medicaid agency).

The CMS 1500 Template Format

The CMS 1500 claim form is readily available from office supply stores, the U.S. Government Printing Office, and local print companies throughout the country. The format of CMS 1500 claim form is available in single, multiple, laser, continuous feed and other options for your choice, totally depending on the printer you are using and your requirements.

Hcfa 1500 Claim Form Free Download 2017

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. If the user would like to complete the form online, simply download, click inside the box to begin and begin typing your information. If the user prefers to hand-write the information, print the form and fill it out by hand.

How To Write

Step 1 – Section 1 – Patient Information –

Cms 1500 Printable Form Free

1a -Begin by entering the insured’s ID number under the appropriate insurer then continue to complete all of the blocks as follows:
2 – Patient name
3- Patient’s Date of Birth mm/dd/yyyy and indicate if patient is male or female
4 – Insured’s Name (last, first, MI)
5 – Patient’s address (number, street)
6 – Patient relationship to insured
7 – Insured’s address (number, street) – City, State, Zip and telephone number with area code
8 – Reserved for NUCC Use
9 – Other insured’s name (last, first, MI)
9a – Other insured’s policy or group number
9b and 9c – Reserved For NUCC Use
9d – Insurance plan name or program name
10 – Is patient’s condition related to – enter an X next to yes or no from a through c in the number 10 block
11 – Insured’s policy number, group or FECA number
11a – Insured’s date of birth mm/dd/yyyy and place an X next to the sex of the insured
11b – Other claim ID provided by NUCC
11c – Insurance plan or program name
11d – Is there another health insurance plan (yes or no)
12- Read the information in box 12 referring to the agreement to release medical information and granting permission for the insurance company to pay the provider- Then provide signature and date
13 – Insured’s or authorized signer must read block 13 and provide signature

Step 2 – Section 2 – Provider Information –

Hcfa 1500 Claim Form Instructions

14 – Date of current illness, injury or pregnancy
15 – Other Date mm/dd/yyyy
16 – Dates patient is unable to work in current occupation
17 – Name of referring provider or other source
18 – Hospitalization dates related to current services
19 – Additional claim information (designated by NUCC)
20 – Outside Lab? What are the charges?
21 – Diagnosis or nature of illness or injury
22 – Resubmission code and original ref. number
23 – Prior authorization number
24a – Dates of service
24b -Place of service
24c – EMG
24d – Procedures, services or supplies (explain if any unusual procedures have been performed)
24e – Diagnosis pointer
24f – Charges
24g – Days or units
24h – Family plan
24i – ID Qual.
24j – Rendering provider number
25 – Federal Tax ID – EIN or SSN
26 -Patient’s accounting number
27 – Accept assignment?
28 – Total charge
29- Total paid
30 – Balance due
31 – Signature of physician or provider, complete with degrees and/or credentials – SIgnature and Date
32. Service facility location information
33 – Billing provider information and telephone number

Zebragol