Physician s/supplier s billing name address zip code and phone 24j Enter the total charge for this claim. This is the total of all charges for each service noted in Field services billed on this claim. any amount entered in Field 29. NOTE The person rendering care must sign and indicate licensure level. rendered. Not Form CMS-1500 08-05 as early as October 1 2006. NOTE The person rendering care must sign and indicate licensure level. rendered. Not Form CMS-1500 08-05 as early as October 1...
cms 1500 form

Get the free cms 1500 form

Fill form 1500: Try Risk Free
Get, Create, Make and Sign cms 1500 printable form
  • Get Form
  • eSign
  • Fax
  • Email
  • Add Annotation
  • Share
Comments and Help with 1500 form pdf
Video instructions and help with filling out and completing cms 1500 form
Instructions and Help about hcfa 1500 claim form

This is Allyson pigeon with practice of the practice today we're going to be going over how a health insurance claim form should look when you submit it to insurance to get reimbursed so let me say a couple things before we jump in to how to fill out the form first of all I don't actually literally type into this form every time I want to submit a claim I have an electronic health record once information is in there it populates the form for me so but I think it's important for you to sort of see what the claim form should look like so that way you can catch any potential mistakes or if there's a problem with a claim you can look at it quickly and see where maybe a mistake was made that can be corrected so let's go over this claim form for Taylor Swift so the first part is box 1 usually what's checked is the other box is just asking what type of plan they have obviously if you're billing Medicare Medicaid you're going to check those boxes over here and then 1a is simply the ID number that's on the insurance card so I always recommend that you get a copy of the insurance card when they come for their first visit that way if there's any issues or if you need to call the 1-800 number on the back you have that specific information for that client and then 2 3 5 a pretty self-explanatory name birth date of the patient their address their phone number you would fill out a 4 if the client had insurance through someone else so if they have insurance through themselves you don't have to worry about that section but if they have it through a parent then or a spouse this is where you would fill in that information so in box for Taylor Swift has insurance or her dad not so Swift get it and so I have to fill in all his information so in box 7 I have to fill out his address his phone number over here in box 6 I don't know why it's checked other it should actually be checked child so I'll change that and then box 11 is the group number again that's listed on the card and this is the dad's birthdate and dad's gender listed so that's all really important that if the insurance is through someone else you need to fill in all this information so if it's not you don't need to fill it out so for box 10 they're asking is the condition related to the following things typically for mental health counseling the answer is always no and then the other thing you have to pay attention to on this top half of the form is this 11d so they're asking is there another health benefit plan so this would be if somebody has both a primary and a secondary insurance so if they do obviously you'd have to check yes and then over here you'd have to write down in boxes nine a through D what the other insurance is so that could actually be a whole nother blog post or video in and of itself about how to build a primary in a secondary insurance so we're not going to get into that today but for this example I just put know she doesn't have another insurance so in boxes 12 and 13 because this is...