Insurance Claim Form 1500
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.
Insurance claim form 1500. If item 9 is completed the patient s signature authorizes release of the information to the health plan or agency shown. Claims must be made within 12 months after services are provided. For medical assistance processing the top right side of the cms 1500 must be blank. Cms hhs websites cms global footer.
Expiration date of 2020 03 31 pending o m b. See 42 cfr 411 24 a. Centers for medicare medicaid services. 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.
If the user would like to complete the form online simply download click inside the box to begin and begin typing your information. Please print or typeapproved omb 0938 0008 form cms 1500 12 90 form rrb 1500 approved omb 1215 0055 form owcp 1500 approved omb 0720 0001 champus because this form is used by various government and private health programs see separate instructions issued by applicable programs. Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. 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.
A federal government website managed and paid for by the u s. Download cms claim form 1500which is used by health care professionals to bill medicare and medicaid. Continue to use the current cms form 1500 02 12 beyond the o m b. Health insurance common claims form.
Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es. Instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness compensation program act of 2000 eeoicpa.
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