Printable Cms 1500 Form 02 12

Its important to adhere to certain guidelines when completing the form to ensure your claims are processed smoothly and quickly.

Printable cms 1500 form 02 12. Please print or type approved omb 0938 1197 form 1500 02 12. Centers for medicare medicaid services. The cms 1500 form is the standard paper claim form used by a non institutional provider or supplier to bill medicare carriers and medicare administrative contractors macs when a provider qualifies for a waiver from the administrative simplification compliance act asca requirement for electronic submission of claims. Print the back side as well to ensure the claim will be accepted.

Cms 1500 pdf home a federal government website managed and paid for by the us. Resubmitting a denied claim is not considered an adjustment or void. Insureds date of birth b. Type print and save your claim using a mac or pc.

7500 security boulevard baltimore md 21244. Insureds address no street city state zip code telephone include area code 11. The cms 1500 is a standard form used to transmit healthcare claims and is used by pinnacol assurance for processing claims. The cms hcfa 1500 form is the standard paper claim form used by a non institutional provider or supplier to bill medicare carriers and medicare administrative contractors macs when a provider qualifies for a waiver from the administrative simplification compliance act asca requirement for electronic submission of claims.

Patient s name last name first name middle initial f 6. Insureds policy group or feca number a. Please print or type approved omb 0938 1197 form 1500 02 12 carrier health insurance claim form approved by national uniform claim committee nucc 0212 pica medicaid tricare id dod group health plan id champva medicaid member id feca blk lung 3. Insureds name last name first name middle initial 7.

The cms 1500 pdf hcfa 1500 pdf is used by all health care providers to bill for services. Updated 12242018 cms 1500 02 12 claim form instructions pv07272017 2 adjustmentvoid reason codes for field 22 to adjust or void a previously paid claim use an adjustment or void reason code to complete the code area of field 22 resubmission code. Free hcfacms 1500 form template for medical claims in fillable format. Approved omb 0938 1197 form 1500 02 12 1a.

Download the fillable hcfa 1500 claim form that is both a fillable andor printable medical claim form that will provide insurance illness and injury information for medical services claimsif the user would like to complete the form online simply download click inside the box to begin and begin typing your information. Patient s birth date dd yy mm 2.