HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
(SSN or ID)
3. PATIENT’S BIRTH DATE
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
OTHER 1a. INSURED’S I.D. NUMBER
4. INSURED’S NAME (Last Name, First Name, Middle
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
TELEPHONE (Include Area Code)
TELEPHONE (Include Area Code)
7. INSURED’S ADDRESS (No., Street)
8. PATIENT STATUS
(For Program in Item 1)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
RED’S DATE OF BIRTH
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
RANCE PLAN NAME OR PROGRAM NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT P
10d. RESERVED FOR LOCAL USE
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other
ther information necessary
to process this claim. I also request payment of government benefits either to myself or to the partyy who
ho accepts assignment
14. DATE OF CURRENT:
return to and complete item 9 a-d.
PERSON’S SIGNATURE I authorize
13. INSURED’S OR AUTHORIZED P
payment of medical benefits tto the undersigned physician or supplier for
services described below.
ILLNESS (First symptom) OR
INJURY (Accident) OR
b. EMPLOYER’S NA
NAME OR SCHOOL NAME
PATIENT AND INSURED INFORMATION
15. IF PATIENT
T HAS HAD SAME OR SIMILAR ILLNESS. 16. D
PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
RST DATE MM
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate
ate Items 1, 2, 3 or 4 to Item 24E by Line)
22. MEDICAID RESUBMISSION
ORIGINAL REF. NO.
RES, SERVICES, OR SUP
PROVIDER ID. #
DATE(S) OF SERVICE
AL TAX I.D. NUMBER
31. SIGNATURE OF PHYSICIAN
EES OR CREDENTIALS
(I certify that the statements
on the reverse
apply to this bill and are made a part thereof.)
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
govt. claims, see back)
32. SERVICE FACILITY LOCATION INFORMATION
NUCC Instruction Manual available at: www.nucc.org
PLEASE PRINT OR TYPE
28. TOTAL CHARGE
29. AMOUNT PAID
33. BILLING PROVIDER INFO & PH #
30. BALANCE DUE
APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)
PHYSICIAN OR SUPPLIER INFORMATION
23. PRIOR AUTHORIZATION NUMBER
BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may
be guilty of a criminal act punishable under law and may be subject to civil penalties.
REFERS TO GOVERNMENT PROGRAMS ONLY
MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process
the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature
authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health
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. See 42
CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or
CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary
as the full charge,
and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are
e based upon the charge
determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health
insurance program but
makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor
provided in those
sor should be pro
items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.
BLACK LUNG AND FECA CLAIMS
The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions
regarding required proce
diagnosis coding systems.
SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK
I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally
onally furnished by me or were furnished
incident to my professional service by my employee under my immediate personal supervision, except as otherwise
wise expressly permitted
permitted by Medicare or CHAMPUS
For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered
ed under the physician’s immediate
mmediate personal supe
by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service,
e, 3) tthey must be of kinds commonly
only furnished in ph
offices, and 4) the services of nonphysicians must be included on the physician’s bills.
For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active
ve duty membe
member of the Unifor
med Services or a civ
of the United States Government or a contract employee of the United States Government, either
ivilian or military (refer to 5 USC
C 5536). For B
I further certify that the services performed were for a Black Lung-related disorder.
No Part B Medicare benefits may be paid unless this form is received as required by existing
sting law and regulations (42 CFR 424.32).
NOTICE: Any one who misrepresents or falsifies essential information to receive payment
ent from Federal funds requested by this form
form may upon conviction be subject
to fine and imprisonment under applicable Federal laws.
NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK L
(PRIVACY ACT STATEMENT)
We are authorized by CMS, CHAMPUS and OWCP to ask you for information
Medicare, CHAMPUS, FECA, and Black Lung
ation needed in the administration of the Medicar
programs. Authority to collect information is in section 205(a), 1862, 1872
nd 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and
44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC
613; E.O. 9397.
C 8101 et seq; and 30 USC 901 et seq; 38 USC 6
The information we obtain to complete claims under these programs
eligibility. It is also used to decide if the services
ms is used to identify you and to determine your el
and supplies you received are covered by these programs and
d to insure that proper payment is mad
The information may also be given to other providers of services,
boards, health plans, and other organizations or Federal
ces, carriers, intermediaries, medical review boar
agencies, for the effective administration of Federal provisions
primary to Federal program, and as otherwise necessary
s that require other third parties payers to pay pr
to administer these programs. For example, it may be necessary
you have used to a hospital or doctor. Additional disclosures
ecessary to disclose information about the benefits yyo
are made through routine uses for information contained
ined in systems of records.
FOR MEDICARE CLAIMS: See the notice modifying
Medicare Claims Record,’ published in the Federal Register, Vol. 55
ying system No. 09-70-0501, titled, ‘Carrie
No. 177, page 37549, Wed. Sept. 12, 1990, orr as updated and republished.
FOR OWCP CLAIMS: Department of Labor,
r, Privacy Act of 1974, “Republication of Notice o
of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28,
1990, See ESA-5, ESA-6, ESA-12, ESA-13,
A-13, ESA-30, or as updated and republished.
medical care provided by civilian sources and to issue payment upon establishment
FOR CHAMPUS CLAIMS: PRINCIPLE
( ) To evaluate eligibility for me
of eligibility and determination thatt the services/supplies
pplies received are authorized b
ROUTINE USE(S): Information
n from claims and related documents may be give
given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or
the Dept. of Transportation consistent
responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of
onsistent with their statutory administrative respon
the Secretary of Defense in
private collection agencies, and consumer reporting agencies in connection with recoupment
n civil actions; to the Internal Revenue Service, pr
claims; and to Congressional
onal Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made
to other federal, state,
business entities, and individual providers of care, on matters relating to entitlement, claims
cal, foreign government agencies, private bu
adjudication, fraud,, program
assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and
m abuse, utilization review, quality assura
n related to the operation of CHAMPUS.
information will result in delay in payment or may result in denial of claim. With the one exception discussed
RES: Voluntary; however,
owever, failure to provide informa
refusing to supply information. However, failure to furnish information regarding the medical services rendered
re are no penalties under
nder these programs for refusi
or the amount
under these programs. Failure to furnish any other information, such as name or claim number, would delay
mount charged would prevent payment of cclaims un
information under FECA could be deemed an obstruction.
ent of the claim. Failure to provide medica
It iss mandatory that you tell us if you know that a
another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801anothe
3812 provide penalties for withholding this info
“Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.
You should be aware that P.L. 100-503, the “Com
MEDICAID PAYMENTS (PROVIDER CERTIFICATION)
are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish
I hereby agree to keep such record
records as a
information regarding any paymen
payments cclaimed for providing such services as the State Agency or Dept. of Health and Human Services may request.
payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception
her agree to accept, as paym
coinsurance, co-payment or similar cost-sharing charge.
d deductible, coinsu
PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were
URE OF PHYSICIA
me or my employee under my personal direction.
y furnished by m
certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State
NOTICE: This is to cert
funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland
21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Medicare Billing: 837P and Form CMS-1500
What are the 837P and Form CMS-1500?
Medicare FFS Contractors include
The 837P (Professional) is the standard format used by health care
A/B Medicare Administrative
professionals and suppliers to transmit health care claims
Contractors (MACs) and Durable
electronically. The Form CMS-1500 is the standard paper claim form Medical Equipment (DME) MACs.
to bill Medicare Fee-For-Service (FFS) Contractors when a paper
claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for
billing various government and some private insurers.
Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing
specifications are consistent with the hard copy data set to the extent that one processing system can
handle both. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (08/05) and the form
is referred to throughout this fact sheet as the CMS-1500.
ANSI ASC X12N 837P
The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional)
Version 5010A1 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
P = Professional version of the 837 electronic format
Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA)
electronic transaction standards for health care professionals and suppliers.
The National Uniform Claim Committee (NUCC) has developed a crosswalk between the ASC X12N 837P and the
hard copy claim form located on the Internet. Medicare FFS Contractors may also include a crosswalk on
CPT Disclaimer-American Medical Association (AMA) Notice
CPT only copyright 2012 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
Implementation and Companion Guides for Electronic Transactions
ASC X12N Implementation Guides are the specific technical instructions for implementing each of the adopted
HIPAA standards and provide instructions on the content and format requirements for each of the standards’
requirements. Implementation Guides are written for use by all health benefit payers, not specifically for
Medicare. Implementation Guides, including Version 5010 Consolidated Guides, are found at
http://www.wpc-edi.com on the Internet.
Companion Guides are issued by CMS and health plans in an effort to provide the most up-to-date information
related to how standard transactions must be submitted to that specific plan. Medicare Companion Guides
provide further instructions identified as situational in an Implementation Guide and are accessed by visiting the
Medicare Fee-for-Service Companion Guides web page.
Medicare Claims Submissions
The “Medicare Claims Processing Manual” (Internet-Only Manual Publication [IOM Pub.] 100-04) is found on the IOM
web page. This publication includes instructions on claims submission. Chapter 1 includes general billing requirements
for various health care professionals and suppliers. Other chapters offer claims submission information specific to a
health care professional or supplier type. Once in IOM Pub. 100-04, look for a chapter(s) applicable to your health care
professional or supplier type and then search within the chapter for claims submission guidelines. For example, Chapter
20 is entitled “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).”
Visit Chapter 24 to learn more about electronic filing requirements, including the Electronic Data Interchange (EDI)
enrollment form that must be completed prior to submitting Electronic Media Claims (EMCs) or other EDI transactions
to Medicare. Refer to Chapter 26 to learn what should be included in the 837P or in each item of the CMS-1500. The
“Medicare Benefit Policy Manual” (IOM Pub. 100-02) and the “Medicare National Coverage Determinations (NCD)
Manual,” (IOM Pub. 100-03) both include coverage information that may be helpful in claims submission. Search for
coverage guidance once within a chapter.
Correct coding is key to submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis
and procedure codes and code them to the highest level of specificity (maximum number of digits) available. Chapter
23 of the “Medicare Claims Processing Manual” is entitled “Fee Schedule Administration and Coding Requirements” and
includes information on diagnosis coding and procedure coding, as well as instructions for codes with modifiers.
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), is currently used to code
diagnostic information on claims. The United States Go ...
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