HCFA 1500 was a form used by health care providers and suppliers to bill Medicare and Medicaid carriers. The new form being used is CMS-1500, which is basically the same form with an added line for the National Provider Identifier (NPI) number. If you are a medical provider or supplier, you must only use CMS-1500 form or you will not be reimbursed. Filling out the CMS-1500 will require information from your patient, diagnosis information and provider information.
Instructions
1. Fill in the patient's information in boxes one through 12. The information required is stated on the line. It will include medical insurance category, patient name, patient date of birth, sex, address, patient status, patient condition and patient signature. Make sure the patient signs the form on line 12 before he leaves the office. Place "n/a" for any box that is not applicable.
2. Fill in the patient's insurance information in boxes 1a to 13. Enter the insurance information from the patient's insurance card, including ID number, insured's name, address, policy group number, date of birth, sex, employers name and signature. Have the patient sign box 13. Place "n/a" for any box that is not applicable.
3. Enter in the diagnosis information in boxes 14 through 24. Enter the date of first symptom, name of referring provider, dates patient is unable to work, hospitalization dates, outside lab, diagnosis, medicaid resubmission code (if it is a refilling of a previously submitted claim) and date of service. Write "n/a" on any line that does not apply.
4. Fill in provider information and billing information in lines 25 to 33. Enter your federal tax number, account number, total charge, amount paid, balance due, signature of physician or supplier, address of location and phone number of billing provider (if using a third-party billing service). It is important that you enter in line 25 your federal tax number or the payment will be delayed. You can now submit your CMS-1500 form for billing.
