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Ambulatory Surgery Center

Sample CMS - 1500 Paper Claim Form

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID PICA TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M F Other Other Part-Time Student OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)

(Medicare #)

(Medicaid #)

(Member ID#)

(ID)

123-45-6789

4. INSURED'S NAME (Last Name, First Name, Middle Initial)

2. PATIENT 'S NAME (Last Name, First Name, Middle Initial)

Smith, Jane N

5. PATIENT 'S ADDRESS (No., Street)

3. PATIENT 'S BIRTH DATE MM DD YY

01

01

19XX

X

Smith, Jane N

7. INSURED'S ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED Self STATE

123 Main Street

CITY

X

Spouse

Child Married

123 Main Street Anytown USA

PATIENT AND INSURED INFORMATION PHYSICIAN OR SUPPLIER INFORMATION

CITY STATE TELEPHONE (Include Area Code)

8. PATIENT STATUS Single

Anytown

ZIP CODE TELEPHONE (Include Area Code)

X

12345

9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) a. OTHER INSURED'S POLICY OR GROUP NUMBER b. OTHER INSURED'S DATE OF BIRTH MM DD YY

( 203 555-1234 )

Employed

Full-Time Student

ZIP CODE

12345

10. IS PATIENT 'S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) YES NO NO NO PLACE (State) b. AUTO ACCIDENT?

11. INSURED'S POLICY GROUP OR FECA NUMBER a. INSURED'S DATE OF BIRTH MM DD YY

( 203 555-1234 )

SEX M

F

SEX M F

b. EMPLOYER'S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO

YES c. OTHER ACCIDENT? YES

c. EMPLOYER'S NAME OR SCHOOL NAME d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE

If yes, return to and complete item 9 a-d.

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 information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED

Enter appropriate diagnosis code(s). ILLNESS (First symptom) Because policies OR INJURY (Accident) OR PREGNANCY(LMP) 01 01 vary, veri cation of 2010 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE covered diagnoses is recommended. 19. RESERVED FOR LOCAL USE

SIGNED 14. DATE OF CURRENT: MM DD YY

DATE

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM DD YY MM DD YY GIVE FIRST DATE MM FROM TO

17a. 17b. NPI

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $ CHARGES

FOR MEDICARE, USE CODE YES NO Include appropriate 0192T, Insertion of anterior 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION ORIGINAL REF. NO. segment aqueous drainage CODE modi ers 365.1X 1. 3. (i.e., -RT or device, without extraocular PRIOR AUTHORIZATION NUMBER -LT) ; 23. reservoir, external approach.

2. 24. A. MM DATE(S) OF SERVICE From To DD YY MM DD YY B. C. PLACE OF SERVICE EMG 4. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DIAGNOSIS POINTER F. $ CHARGES

DAYS OR UNITS

G.

1 2 3 4 5 6

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

01 01 12 01 01 12

01 01 12 01 01 12

24 24

0192T L8612

-RT

1

XXXX XX XXXX XX

NPI NPI NPI NPI NPI NPI

FOR PRIVATE PAYORS, USE BOTH CODES: 0192T, Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach, AND, L8612, Aqueous shunt.

25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT 'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For

govt. claims, see back)

28. TOTAL CHARGE $

29. AMOUNT PAID $

30. BALANCE DUE

YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY LOCATION INFORMATION

NO

33. BILLING PROVIDER INFO & PH #

Anytown, ASC Anytown, USA

a.

(

)

$

NUCC Instruction Manual available at: www.nucc.org

SIGNED

DATE

NPI

b.

a.

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

NPI

b.

* Providers are encouraged to check with commercial carriers for specific coding instructions.

CARRIER

1500

Information

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