Form CMS-1500(02-12) Claim Form

CARRIER

HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA

PICA
TRICARE

CHAMPVA

(ID#/DoD#)

(Member ID#)

GROUP
HEALTH PLAN
(ID#)

FECA
BLK LUNG
(ID#)

3. PATIENT’S BIRTH DATE
MM
DD
YY

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

(ID#)

5. PATIENT’S ADDRESS (No., Street)

F

6. PATIENT RELATIONSHIP TO INSURED

CITY

STATE

8. RESERVED FOR NUCC USE

STATE

CITY

TELEPHONE (Include Area Code)

(

7. INSURED’S ADDRESS (No., Street)

Other

Child

Spouse

Self

ZIP CODE

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

SEX
M

ZIP CODE

TELEPHONE (Include Area Code)

(

)

)

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)

a. INSURED’S DATE OF BIRTH
MM
DD
YY

b. RESERVED FOR NUCC USE

b. AUTO ACCIDENT?

PLACE (State)

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME
NO

YES
d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
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 information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.

15. OTHER DATE

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

QUAL.

MM

DD

YY

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
YY
MM
DD
MM
DD
YY
TO
FROM
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
YY
MM
DD
MM
DD
YY
TO
FROM

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
B.

C.

D.

E.

F.

G.

H.

MM

YY

B.
C.
PLACE OF
SERVICE EMG

NO

22. RESUBMISSION
CODE

ICD Ind.

A.

J.

$ CHARGES

20. OUTSIDE LAB?
YES

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

If yes, complete items 9, 9a, and 9d.

SIGNED

17b. NPI

I.
24. A.

NO

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

DATE

SIGNED
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
MM
DD
YY
QUAL.

F

b. OTHER CLAIM ID (Designated by NUCC)

NO

YES
c. RESERVED FOR NUCC USE

SEX
M

NO

YES

ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

K.
L.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER

E.
DIAGNOSIS
POINTER

F.
$ CHARGES

H.

G.

I.

J.
RENDERING
PROVIDER ID. #

EPSDT
ID.
Family
Plan QUAL.

DAYS
OR
UNITS

1

NPI

2

NPI

3

NPI

4

NPI

5

NPI

6

NPI

25. FEDERAL TAX I.D. NUMBER

SSN EIN

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?
(For

govt. claims, see back)

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.)

SIGNED

DATE

NO

32. SERVICE FACILITY LOCATION INFORMATION

a.

NUCC Instruction Manual available at: www.nucc.org

NPI

PATIENT AND INSURED INFORMATION

MEDICAID

(Medicaid#)

(For Program in Item 1)

b.

PLEASE PRINT OR TYPE

28. TOTAL CHARGE
$

$

33. BILLING PROVIDER INFO & PH #

a.

30. Rsvd for NUCC Use

29. AMOUNT PAID

NPI

(

)

b.

OMB APPROVAL PENDING

PHYSICIAN OR SUPPLIER INFORMATION

MEDICARE

(Medicare#)

1.

OTHER 1a. INSURED’S I.D. 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 TRICARE 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 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 TRICARE participation cases, the physician agrees to accept the charge determination of the Medicare carrier or TRICARE fiscal intermediary as the full charge and
the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or
TRICARE fiscal intermediary if this is less than the charge submitted. TRICARE is not a health insurance program but makes payment for health benefits provided through certain affiliations
with the Uniformed Services. Information on the patient’s sponsor should be provided in those 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 regarding required procedure and diagnosis coding systems.
SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, TRICARE, FECA AND BLACK LUNG)

In submitting this claim for payment from federal funds, I certify that: 1) the information on this form is true, accurate and complete; 2) I have familiarized myself with all applicable laws,
regulations, and program instructions, which are available from the Medicare contractor; 3) I have provided or will provide sufficient information required to allow the government to make an
informed eligibility and payment decision; 4) this claim, whether submitted by me or on my behalf by my designated billing company, complies with all applicable Medicare and/or Medicaid
laws, regulations, and program instructions for payment including but not limited to the Federal anti-kickback statute and Physician Self-Referral law (commonly known as Stark law); 5) the
services on this form were medically necessary and personally furnished by me or were furnished incident to my professional service by my employee under my direct supervision, except as
otherwise expressly permitted by Medicare or TRICARE; 6) for each service rendered incident to my professional service, the identity (legal name and NPI, license #, or SSN) of the primary
individual rendering each service is reported in the designated section.For services to be considered "incident to" a physician's professional services, 1) they must be rendered under the
physician's direct supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician service, 3) they must be of kinds commonly furnished in
physician's offices, and 4) the services of non-physicians must be included on the physician's bills.
For TRICARE claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employee of the United States
Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims, 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 law and regulations (42 CFR 424.32).
NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment
under applicable Federal laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, TRICARE, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT)
We are authorized by CMS, TRICARE and OWCP to ask you for information needed in the administration of the Medicare, TRICARE, FECA, and Black Lung programs. Authority to collect
information is in section 205(a), 1862, 1872 and 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 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.
The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received
are covered by these programs and to insure that proper payment is made.
The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federal agencies, for the effective
administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary to administer these programs. For example, it may
be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained in systems of
records.
FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55 No. 177, page 37549,
Wed. Sept. 12, 1990, or as updated and republished.
FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28, 1990, See ESA-5, ESA-6,
ESA-12, ESA-13, ESA-30, or as updated and republished.
FOR TRICARE CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and
determination that the services/supplies received are authorized by law.
ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation
consistent with their statutory administrative responsibilities under TRICARE/CHAMPVA; to the Dept. of Justice for representation of the Secretary of Defense in civil actions; to the Internal
Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment claims; and to Congressional 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, local, foreign government agencies, private business entities, and individual
providers of care, on matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability,
coordination of benefits, and civil and criminal litigation related to the operation of TRICARE.
DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussed below, there are no
penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent
payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay payment of the claim. Failure to provide medical information
under FECA could be deemed an obstruction.
It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801-3812 provide penalties
for withholding this information.
You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.

MEDICAID PAYMENTS (PROVIDER CERTIFICATION)
I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish information regarding any
payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.
I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible,
coinsurance, co-payment or similar cost-sharing charge.
SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by
me or my employee under my personal direction.
NOTICE: This is to 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 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 XXXX-XXXX. 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, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.