Health Insurance Claim Forms by xln10969

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									 Health Insurance
 Claim Forms




CMS-1500 for Private Practice             PLIAN
                                                CE
                                      COM FIED
UB-04 for Hospitals and Institutions   CERTI
Claim Forms for Dental Offices
Compatible Envelopes for easy filing
Form Filler Software to automate your claim forms
                        1325 South Creek Drive, Suite 500, Houston, TX 77084
                       Phone: 800-354-apex (2739) • Fax 800-600-apex (2739)
                      Website: www.apextax.com • e-mail: o ce@apextax.com
   business systems   Shipping locations in Texas, Pennsylvania and California
    What you need to know about
    Healthcare Claim Forms...

    Compliance is critical for medical claim forms...
    If you le a claim with a form that is not up to date and fully compliant the payer may reject the form, causing a
    delay in you, the provider, receiving payment.

    What makes a form compliant or non-compliant?
    A number of factors... for starters it must adhere to strict printing standards that govern the layout, the paper
    and the ink. It must also have accurate content like the NPI - the National Provider Identi er and it must
    conform to the HIPAA - Health Insurance Portability and Accountability Act.

    How can I be sure that my forms are up-to-date and fully compliant?
    Two things... rst of all, ask us. We can check your current supply of forms. Secondly be sure to order from this
    catalog. All the forms inthis catalog were developed in conjunction with all the governing agencies including
    the NUCC - National Uniform Claim Committee, the NUBC - National Uniform Billing Committee, the CMS -
    Centers for Medicare and Medicaid Services, the HHS - Health and Human Services agency of the US Govern-
    ment and the AHA - American Hospital Association. We are the only provider selected to work exclusively with
    these agencies in the development of the current forms and are in constant contact with all agencies to be on
    top of the latest revisions and requirements.

    Table of Contents
    Form CMS-1500 - page 3
    For private practice providers and anyone billing within the non-institutional medical industry
    Form UB-04 - page 4
    For hospitals, skilled nursing, home health care facilities and other institutional healthcare
    providers
    Attending Dentist’s Statements - page 5
    All the claim forms o cially licensed by the ADA and supported by the most popular dental
    software packages
    Compatible Envelopes - page 6
    Standard and Jumbo envelopes compatible with the CMS-1500, UB-04 and ADA forms
    CMS-1500 Form Filler Software - page 7
    For private practice providers and anyone billing within the non-institutional medical industry
    Form UB-04 Form Filler Software - page 8
    For hospitals, skilled nursing, home health care facilities and other institutional health care
    providers

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CMS-1500 Health Insurance Claim Forms
for use by Private Practitioners
Accommodates reporting of your
NPI - National Provider Identi er.

Designed for processing on
high speed OCR scanning equipment.

Printed in special red “dropout” ink
on basis weight 20# paper.

Available for laser, continuous form
pin-feed and snap-apart sets.

Optional pressure sensitive mailing
label available on continuous forms.
Label is blown-on, self-imaging.

Laser Cut Sheets
Item # CMSLC - Single sheet - 2,500 per case

Continuous Forms
Item # CMS1 - 1 part form - 2,500 per case
Item # CMS2 - 2 part form - 1,000 per case
       Paper sequence: White/Canary
Item # CMSW2 - 2 part form - 1,000 per case
       Paper sequence: White/White
Item # CMS3 - 3 part form - 1,000 per case
       Paper sequence: White/Canary/Pink

Continuous Forms with Labels
Item # CMS1B - 1 part form - 1,000 per case
Item # CMS2B - 2 part form - 1,000 per case
       Paper sequence: White/Canary

2-Part Snap-Apart Forms
Item # CMSS - 2 part form - 500 per case
       Paper sequence: White/Canary

See our Form Filler Software
for CMS-1500 on page 7


                                               3
    UB-04 Health Insurance Claim Forms
    for Hospitals and Institutions
    As of March 1, 2007 the UB-04 replaced
    the UB-92. The form is designed for
    hospitals to le a medical claim with
    the patient’s insurance carrier.

    Designed for processing on
    high speed OCR scanning equipment.

    Printed in special red “dropout” ink
    on basis weight 20# paper.

    Available for laser and continuous form
    pin feed with up to ve parts. All parts
    are printed on white carbonless stock.

    Laser Cut Sheets
    Item # UB04LC - Single sheet - 2,500 per case

    Continuous Forms
    Item # UB041 - 1 part form - 2,500 per case
    Item # UB042 - 2 part form - 2,500 per case
    Item # UB043 - 3 part form - 1,000 per case
    Item # UB044 - 4 part form - 500 per case
    Item # UB045 - 5 part form - 500 per case

    See our Form Filler Software
    for UB-04 on page 8




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Attending Dentist’s Statements
authorized by the ADA
The American Dental Association (ADA)
has authorized a number of di erent
claim/attending dentist’s forms over
the years. We inventory those versions
that are supported by the greatest
number of dental software packages.
We have been o cially licensed by the
ADA to produce the following versions:
2006, 2004, 2000, 1994, 1990, 1987 and
1985.

2006 Series
Item # 2600 - 2006 Laser-Cut Sheet - 2,500 per case
Item # 2601 - 2006 1-Part Continuous - 2,500 per case
Item # 2602 - 2006 2-Part Continuous - 1,000 per case
2004 Series
Item # 2400 - 2004 Laser-Cut Sheet - 2,500 per case
Item # 2401 - 2004 1-Part Continuous - 2,500 per case
Item # 2402 - 2004 2-Part Continuous - 1,000 per case
2000 Series
Item # 2000 - 2000 Laser-Cut Sheet - 2,500 per case
Item # 2001 - 2000 1-Part Continuous - 2,500 per case
Item # 2002 - 2000 2-Part Continuous - 1,000 per case
Item # 2002S - 2000 2-Part Snap-Apart - 500 per case
1994 Series
Item # 1940 - 1994 Laser-Cut Sheet - 2,500 per case
Item # 1941 - 1994 1-Part Continuous - 2,500 per case
Item # 1942 - 1994 2-Part Continuous - 1,000 per case
Item # 1942S - 1994 2-Part Snap-Apart - 500 per case
1990 Series
Item # 900 - 1990 Laser-Cut Sheet - 2,500 per case
Item # 901 - 1990 1-Part Continuous - 2,500 per case
Item # 902 - 1990 2-Part Continuous - 1,000 per case
1987 Series
Item # 870 - 1987 Laser-Cut Sheet 2,500 per case
Item # 871 - 1987 1-Part Continuous 2,500 per case
Item # 872 - 1987 2-Part Continuous 1,000 per case
1985 Series
Item # 1850 - 1985 Laser-Cut Sheet 2,500 per case
Item # 1851 - 1985 1-Part Continuous - 2,500 per case
Item # 1852 - 1985 2-Part Continuous - 1,000 per case
Item # B1852 - 1985 2-Part Cont. Label - 1,000 per case



                                                          5
    Compatible Claim Form Envelopes
    CMS-1500, UB-04, ADA
    Jumbo Envelopes for
    CMS-1500 and UB-04 Claim Forms
    As more insurance companies convert to
    optically scanning your claim forms the need
    to mail them unfolded becomes increasingly
    important. When claim forms are folded they
    may jam the automatic scanning equipment
    and delay the processing of claims. One way
    to prevent these delays is to mail claim forms
    in our jumbo envelope. This 9” x 12-1/2”
    self-sealing window envelope holds up to 50
    unfolded forms. Jumbo envelopes come 500
    per case.

    Item #1500LR - Jumbo Envelope
           for CMS-1500 with Right Window
    Item #1500RS - Jumbo Envelope
           for CMS-1500, Right Window, no wording
    Item #1492LL - Jumbo Envelope
           for UB-04 with Left Window

    CMS-1500 Window Envelopes
    Our traditional #10-1/2 window envelope
    holds up to 12 claim forms. It is available with
    either a gum-seal or self-seal. Three line
    address on front or back of envelope in black
    ink is available. 500 per case.
                                                       Jumbo Envelope
    Item #1500ES - Self Seal Style
    Item #1500E - Gum Seal Style

    ADA Window Envelopes
    Our ADA window envelope selection o ers
    compatibility with our entire line of Attending
    Dentist’s Statements. 500 per case.
    Item # 2003ES - Version 2006 & 2004
    Item # 2000ES - Version 2000
    Item # 1994ES - Versions 1994, 1990, 1987, 1985


                                                       Window Envelope




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Speedy Claims Form Filler Software
for CMS-1500 Claim Forms
Get paid faster with the ultimate in CMS-1500
software - Speedy Claims is what you need to
print and le your paper claims quickly and
easily to all your insurance payers.
Simpler to use than other form ller software
Free updates with no add-on costs
Free technical support is included
Automatic backup of all your data
Lower cost than other form ller software
Choose CD ROM, Download or Flash Drive

Speedy Claims for Paper Claim Filing
The ultimate CMS-1500 software... Speedy Claims
is what you need to complete and file paper claim
forms quickly and easily.
Speedy Claims for Electronic Claims
All the features of Speedy Claims plus the ability
to send your claims electronically. You can print
and/or create a file that can be sent to a clearing-
house for electronic filing.

Professional Speedy Claims
Perfect for Medical Billing Agencies and practices
that bill for multiple providers. The software
creates a separate database for each provider. For
example, when the user selects Dr. Green they see
and use his information only. When they switch to
Dr. Brown they no longer see Dr. Green’s data. For
electronic ling only.

Paper Version Software (Paper filing only)
Item # CMSDL - Speedy Claims1500 - Download
Item # CMSCD - Speedy Claims1500 - CD Disc
Item # CMSFD - Speedy Claims1500 - Flash Drive

Electronic Version (Paper or electronic filing)
Item # CMSDLE - Speedy Claims1500 - Download
Item # CMSCDE - Speedy Claims1500 - CD Disc
Item # CMSFDE - Speedy Claims1500 - Flash Drive
                                                       Available as CD ROM, Download or Flash Drive
Professional Version (Electronic filing only)
Item # CMSDLP - Speedy Claims1500 - Download
Item # CMSCDP - Speedy Claims1500 - CD Disc
Item # CMSFDP - Speedy Claims1500 - Flash Drive

                                                                                                      7
    Speedy Claims Form Filler Software
    for UB-04 Claim Forms
    Get paid faster with the ultimate in UB-04
    software - Speedy Claims is what you need to
    print and le your paper claims quickly and
    easily to all your insurance payers.
    Simpler to use than other form ller software
    Free updates with no add-on costs
    Free technical support is included
    Automatic backup of all your data
    Lower cost than other form ller software
    Choose CD ROM, Download or Flash Drive

    Speedy Claims for Paper Claim Filing
    The ultimate UB-04 software... Speedy Claims is
    what you need to complete and file paper claim
    forms quickly and easily.
    Speedy Claims for Electronic Claims
    All the features of Speedy Claims plus the ability
    to send your claims electronically. You can print
    and/or create a file that can be sent to a clearing-
    house for electronic filing.

    Professional Speedy Claims
    Perfect for Medical Billing Agencies and practices
    that bill for multiple providers. The software
    creates a separate database for each provider. For
    example, when the user selects Dr. Green they see
    and use his information only. When they switch to
    Dr. Brown they no longer see Dr. Green’s data. For
    electronic ling only.

    Paper Version Software (Paper filing only)
    Item # UBDL - Speedy Claims UB04 - Download
    Item # UBCD - Speedy Claims UB04 - CD Disc
    Item # UBFD - Speedy Claims UB04 - Flash Drive

    Electronic Version (Paper or electronic filing)
    Item # UBDLE - Speedy Claims UB04 - Download
    Item # UBCDE - Speedy Claims UB04 - CD Disc
    Item # UBFDE - Speedy Claims UB04 - Flash Drive
                                                           Available as CD ROM, Download or Flash Drive
    Professional Version (Electronic filing only)
    Item # UBDLP - Speedy ClaimsUB04 - Download
    Item # UBCDP - Speedy Claims UB04 - CD Disc
    Item # UBFDP - Speedy Claims UBO4 - Flash Drive

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