1500 Health Insurance Claim Form Sample - PDF

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1500 Health Insurance Claim Form Sample - PDF Powered By Docstoc
					     1500




                                                                                                                                                                                                                                    CARRIER
    HEALTH INSURANCE CLAIM FORM
    APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
               PICA                                                                                                                                                                                                        PICA

    1.    MEDICARE            MEDICAID             TRICARE                CHAMPVA               GROUP                  FECA                  OTHER 1a. INSURED’S I.D. NUMBER                             (For Program in Item 1)
                                                   CHAMPUS                                      HEALTH PLAN            BLK LUNG
          (Medicare #)       (Medicaid #)         (Sponsor’s SSN)         (Member ID#)          (SSN or ID)            (SSN)                 (ID)

    2. PATIENT’S NAME (Last Name, First Name, Middle Initial)                          3. PATIENT’S BIRTH DATE                     SEX              4. INSURED’S NAME (Last Name, First Name, Middle Initial)
                                                                                           MM     DD      YY
                                                                                                                        M                F
    5. PATIENT’S ADDRESS (No., Street)                                                 6. PATIENT RELATIONSHIP TO INSURED                           7. INSURED’S ADDRESS (No., Street)

                                                                                         Self       Spouse        Child             Other

    CITY                                                                   STATE       8. PATIENT STATUS                                            CITY                                                               STATE




                                                                                                                                                                                                                                    PATIENT AND INSURED INFORMATION
                                                                                           Single            Married                Other
    ZIP CODE                               TELEPHONE (Include Area Code)                                                                            ZIP CODE                             TELEPHONE (Include Area Code)
                                                                                                        Full-Time              Part-Time
                                            (         )                                  Employed       Student                Student                                                       (          )
    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

                       Effective May 23, 2008, the fields shaded in green indicate areas to report NPI
    a. OTHER INSURED’S POLICY OR GROUP NUMBER         a. EMPLOYMENT? (Current or Previous)          a. INSURED’S DATE OF BIRTH                                                                                  SEX
                       numbers. It is mandatory for NPI numbers to be provided in these fields for a
                                                                    YES            NO
                                                                                                            MM     DD      YY
                                                                                                                                     M                                                                                 F
                       claim to
    b. OTHER INSURED’S DATE OF BIRTHbe considered valid.
                                         SEX          b. AUTO ACCIDENT?                             b. EMPLOYER’S NAME OR SCHOOL NAME
          MM      DD         YY                                                       PLACE (State)
                                                  M                 F                                   YES                   NO
    c. EMPLOYER’S NAME OR SCHOOL NAME                                                  c. OTHER ACCIDENT?                                           c. INSURANCE PLAN NAME OR PROGRAM NAME

                                                                                                        YES                   NO

    d. INSURANCE PLAN NAME OR PROGRAM NAME                                             10d. RESERVED FOR LOCAL USE                                  d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

                                                                                                                                                             YES           NO          If yes, return to and complete item 9 a-d.
                                  READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.                                                          13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
    12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary                                payment of medical benefits to the undersigned physician or supplier for
        to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment                    services described below.
        below.

          SIGNED                                                                                 DATE                                                      SIGNED
    14. DATE OF CURRENT:                ILLNESS (First symptom) OR             15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
       MM     DD     YY                 INJURY (Accident) OR                       GIVE FIRST DATE MM      DD      YY                    MM    DD      YY            MM    DD      YY
                                        PREGNANCY(LMP)                                                                             FROM                          TO
    17. NAME OF REFERRING PROVIDER OR OTHER SOURCE                              17a.                                                                18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
                                                                                                                                                              MM     DD      YY           MM    DD      YY
                                                                                17b. NPI                                                                FROM                           TO
    Enter the NPI of the
    19. RESERVED FOR LOCAL USE                                                                                                                      20. OUTSIDE LAB?                                 $ CHARGES
    referring/ordering physician                                                                                                                              YES           NO
    listed in OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
    21. DIAGNOSIS Item 17.                                                                                                                          22. MEDICAID RESUBMISSION
                                                                                                                                                        CODE                  ORIGINAL REF. NO.
     1.                                                                          3.
                                                                                                                      case
                                                          Enter the rendering provider's NPI. In the PRIOR AUTHORIZATION NUMBER
                                                                                                                  23.

     2.                                                   of a service 4.  provided incident to the service of
                                                                       (Explain non-physician
                                                          a physician or Unusual Circumstances) practitioner, when
    24. A.                                                B.                                                E.            F.     G.     H.     I.                                                                    J.




                                                                                                                                                                                                                                    PHYSICIAN OR SUPPLIER INFORMATION
                  DATE(S) OF SERVICE                            C. D. PROCEDURES, SERVICES, OR SUPPLIES
               From                To                                                                                           DAYS  EPSDT
                                                       PLACE OF                                         DIAGNOSIS                OR   Family  ID.                                                                RENDERING

                                                          the person who ordered the service is not
     MM        DD     YY     MM   DD             YY    SERVICE EMG  CPT/HCPCS            MODIFIER        POINTER      $ CHARGES UNITS  Plan QUAL.                                                               PROVIDER ID. #

1                                                         supervising, enter the NPI of the supervisor.                                      NPI


2                                                                                                                                                                                                NPI
                                                                         Enter the billing provider's (group/
3                                                                        organization or individual) name,                                                                                       NPI


4                                                                        address, city, state, zip, and
                                                                                                                                                                                                 NPI
                                                                         phone number in Item 33.
5                                                                                                                                                                                                NPI
     Enter the NPI of the
                                                                                                                                                              Enter the NPI for the
6 service facility. Identify
     the suppliers NPI when
 25. FEDERAL TAX I.D. NUMBER      SSN EIN                           26. PATIENT’S ACCOUNT NO.                27. ACCEPT ASSIGNMENT?
                                                                                                                                                              billing provider NPIPAID 30. BALANCE DUE
                                                                                                                                                    28. TOTAL CHARGE
                                                                                                                                                                                  or group/
                                                                                                                                                                         29. AMOUNT

     billing for purchased
                                                                                                                (For

                                                                                                                  YES
                                                                                                                       govt. claims, see back)
                                                                                                                                     NO              $
                                                                                                                                                              organization.
                                                                                                                                                                          $              $

     diagnostic tests.
 31. SIGNATURE OF PHYSICIAN OR SUPPLIER
     INCLUDING DEGREES OR CREDENTIALS
                                                                    32. SERVICE FACILITY LOCATION INFORMATION                                       33. BILLING PROVIDER INFO & PH #             (          )
          (I certify that the statements on the reverse
          apply to this bill and are made a part thereof.)




    SIGNED                                      DATE
                                                                    a.
                                                                              NPI                  b.                                               a.
                                                                                                                                                                NPI               b.

    NUCC Instruction Manual available at: www.nucc.org                                                                                                     APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)