Insurance claims auditing services Forms for Chicago
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FAQ
Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and Page 2 Instructions on how to fill out the CMS 1500 Form telephone number. If Medicare is primary, leave blank.
CMS 1500 Items 1-7: Patient and Insured InformationItem 1: Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other.Item 2: Patient's Name.Item 3: Patient's Birth Date, Sex.Item 4: Insured's Name.Item 5: Patient's Address (multiple fields)Item 6: Patient Relationship to Insured.More items...?
Typical sections of a claim form: Personal information like your name, address and date of birth. Insurance information such as a policy and group number. Reason for your visit including background information about your condition.
Item 17a Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until , and MUST be reported if an NPI is not available.
Item 24E - This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter Page 17 per line item.
The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs.