Form CMS-1500 (08-05) CMS-1500 (08-05) Health Insurance Claim Form

CARRIER

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA

PICA

MEDICARE

MEDICAID

(Medicare #)

(Medicaid #)

TRICARE
CHAMPUS
(Sponsor’s SSN)

GROUP
HEALTH PLAN
(SSN or ID)

CHAMPVA

(Member ID#)

3. PATIENT’S BIRTH DATE
MM
DD
YY

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

OTHER 1a. INSURED’S I.D. NUMBER

FECA
BLK LUNG
(SSN)

(ID)
4. INSURED’S NAME (Last Name, First Name, Middle
le
e IInitial)

SEX
M

5. PATIENT’S ADDRESS (No., Street)

F

6. PATIENT RELATIONSHIP TO INSURED
Self

CITY

STATE

Child

Spouse

STATE
STAT

CITY

Married

Other

TELEPHONE (Include Area Code)

ZIP CODE

TELEPHONE (Include Area Code)
C

A
M
P
LE

ZIP CODE

7. INSURED’S ADDRESS (No., Street)

Other

8. PATIENT STATUS
Single

(For Program in Item 1)

(

)

Employed

Full-Time
Student

Part-Time
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

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

RED’S DATE OF BIRTH
RE
a. INSURED’S
MM
DD
YY

b. OTHER INSURED’S DATE OF BIRTH
MM
DD
YY

b. AUTO ACCIDENT?

SEX

PLACE (State)

c. EMPLOYER’S NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

c. INSURANCE
RANCE PLAN NAME OR PROGRAM NAME

NO

YES

d. INSURANCE PLAN NAME OR PROGRAM NAME

PLAN?
d. IS THERE ANOTHER HEALTH BENEFIT P

10d. RESERVED FOR LOCAL USE
E

YES

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
ne
to process this claim. I also request payment of government benefits either to myself or to the partyy who
ho accepts assignment
below.
SIGNED

14. DATE OF CURRENT:
MM
DD
YY

NO

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

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.
serv

DATE
ATE
TE

ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)

F

b. EMPLOYER’S NA
NAME OR SCHOOL NAME

NO

YES

F

M

SEX

M

NO

YES

FORM
PATIENT AND INSURED INFORMATION

1.

SIGNED

15. IF PATIENT
NT
T HAS HAD SAME OR SIMILAR ILLNESS. 16. D
PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
DATES PATIE
DD
YY
DD
YY
MM
MM
DD
YY
GIVE FIRST
IRST
RST DATE MM
TO
FRO
FROM

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
18. HOSP
MM
DD
YY
MM
DD
YY
FROM
TO
F

17a.

17b.
7
NPI

19. RESERVED FOR LOCAL USE

20. OUTSIDE LAB?
2
YES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate
Relate
ate Items 1, 2, 3 or 4 to Item 24E by Line)
1.

$ CHARGES

NO

22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.

3.

2.
24. A.
MM

1
2
3
4

YY

B.
C.
C
PLACE OF
SERVICE EMG

4.
SUPPLIES
RES, SERVICES, OR SUP
D. PROCEDURES,
(Explain Unusual
usual Circumstanc
Circumstances)
MODIFIER
CPT/HCPCS
MODI
MOD

E.
DIAGNOSIS
POINTER

F.

$ CHARGES

H.

G.

I.

J.
RENDERING
PROVIDER ID. #

EPSDT
ID.
Family
Plan QUAL.

DAYS
OR
UNITS

NPI

NPI

NPI

NPI

S

5

DATE(S) OF SERVICE
From
To
DD
YY
MM
DD

NPI

6

25. FEDERAL
AL TAX I.D. NUMBER

SSN EIN
S

31. SIGNATURE OF PHYSICIAN
OR SUPPLIER
YSIC
INCLUDING DEGREES
EES OR CREDENTIALS
(I certify that the statements
on the reverse
me
apply to this bill and are made a part thereof.)

SIGNED

DATE

NPI

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?
(For

govt. claims, see back)

YES

NO

32. SERVICE FACILITY LOCATION INFORMATION

a.

NUCC Instruction Manual available at: www.nucc.org

NPI

b.

PLEASE PRINT OR TYPE

28. TOTAL CHARGE
$

29. AMOUNT PAID

33. BILLING PROVIDER INFO & PH #

a.

30. BALANCE DUE

$

NPI

$

(

)

b.

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
APPLICABLE PROGRAMS.
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,
ed
edi
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
ealth insura
insuran
makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor
provided in those
nsor
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
ctions
tions regarding
regarding required proce
procedure and
diagnosis coding systems.

LE

SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK
ACK LUNG)
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
regulations.
For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered
supervision
ed under the physician’s immediate
mmediate personal supe
super
by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service,
physician’s
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
Uniformed
civilian employee
tive
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
Black-Lung claims,
her civilian
ivilian or military (refer to 5 USC
C 5536). For B
Bl
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
isting
sting law and regulations (42 CFR 424.32).
424.32).

NOTICE: Any one who misrepresents or falsifies essential information to receive payment
ment
ent from Federal funds requested by this form
form may upon conviction be subject
to fine and imprisonment under applicable Federal laws.

A
M
P

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK L
LUNG INFORMATION
LU
(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
Medicare
programs. Authority to collect information is in section 205(a), 1862, 1872
2 and
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
made.
The information may also be given to other providers of services,
boards, health plans, and other organizations or Federal
vices,
ces, carriers, intermediaries, medical review boar
agencies, for the effective administration of Federal provisions
primary to Federal program, and as otherwise necessary
sions
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
ained
ined in systems of records.
FOR MEDICARE CLAIMS: See the notice modifying
Medicare Claims Record,’ published in the Federal Register, Vol. 55
fying
ying system No. 09-70-0501, titled, ‘Carrie
‘Carrier Medic
No. 177, page 37549, Wed. Sept. 12, 1990, orr as updated and republished.

FOR OWCP CLAIMS: Department of Labor,
or,
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
LE PURPOSE(S):
SE(S):
( ) To evaluate eligibility for me
medica
of eligibility and determination thatt the services/supplies
pplies received are authorized b
by law.
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
priva
claims; and to Congressional
sional
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
e, local,
cal, foreign government agencies, private bu
bus
adjudication, fraud,, program
assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and
m abuse, utilization review, quality assura
criminal litigation
n related to the operation of CHAMPUS.
DISCLOSURES:
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
below, there
refusing to supply information. However, failure to furnish information regarding the medical services rendered
re are no penalties under
nder these programs for refusi
refusin
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
payment
information under FECA could be deemed an obstruction.
ent of the claim. Failure to provide medica
medical inform

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
information.
3812 provide penalties for withholding this info
inform
“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
“Comp

S

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.
I further
payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception
urther
her agree to accept, as paym
payme
of authorized
coinsurance, co-payment or similar cost-sharing charge.
uthorized
d deductible, coinsu
SIGNATURE
PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were
TURE
URE OF PHYSICIA
personally
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.