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Professional Paper Claim Form (CMS-1500) How to Submit Claims: Claims may be electronically submitted to a Medicare carrier, Durable Medical Equipment Medicare Administrative Contractor (DMEMAC), or A/B MAC from a provider's office using a computer with software that meets electronic filing requirements as established by the HIPAA claim ...
please print or type approved omb-0938-1197 form 1500 (02-12) ample please print or type approved omb-0938-1197 form 1500 (02-12) health insurance claim form approved by national uniform claim committee (nucc) 02/12 ... www.nucc.org please print or type 1a. insured’s i.d. number (for program in item 1) 4. insured’s name (last name, first ...
You can find Medicare CMS-1500 completion and coding instructions, as well as the print specifications in Chapter 26 of the Medicare Claims Processing Manual (Pub.100-04).
The CMS-1500 form has three blocks: the Carrier section, the Patient and Insured Information, and the Physician and Supplier Information. We'll focus on specific items with clear but often tricky requirements.
FREE CMS-1500 (HCFA) CLAIM FORM TEMPLATE PDF. DOWNLOAD FREE CMS 1500 CLAIM FORM FILLABLE TEMPLATE. Read the instructions and tips below first. The current version of the original manual from the National Uniform Claim Comettee of how to complete the CMS1500 claim form.
The CMS-1500 (02-12) claim form has the capacity to capture up to four modifiers. Enter the acquisition cost for pharmaceutical or radiopharmaceutical diagnostic imaging agents or for therapeutic radionuclides.
CMS-1500 Claim Form Guidelines and Tips. All paper claims must be submitted on the Revised Form CMS-1500 (02/12). This form is the only version accepted by Medicare. Failure to follow these guidelines could cause a delay in processing, denial of the claim, or affect payment accuracy.
The CMS-1500 Form is the prescribed form for claims prepared and submitted by physicians or suppliers, whether or not the claims are assigned. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.
When CMS allows a paper claim, the Form CMS-1500 is the standard claim form to bill Medicare Administrative Contractors (MACs). CMS allows providers to submit a paper claim if they meet the Administrative Simplification Compliance Act (ASCA) exceptions. Sometimes providers use the 837P and CMS-1500 to bill certain government and private insurers.