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New hcfa 1500 claim form

CMS 1500 Claim Forms - HCFA (Version 08/05) (500 Sheets; Laser/Inkjet Printer).
Hcfa 1500 Forms
The Centers for Medicare & Medicaid Services (CMS) approved a new CMS-1500 form (02/12) to replace the previous form (08/05). Fully updated with the latest revisions ...
Cms 1500 Claim Form Vs. Hcfa - Difference Between Old And New
Fill out hcfa-1500 (CMS 1500) forms on your computer and print the data or submit claims electronically; IMPORTANT newS - hcfa-1500 (02/12) Release
New 2014 Blank Cms-1500 (hcfa) Form Version 02/12 For ...
CMS/HCFA 1500 claim form (New 02/12) version 500 sheets. Mandatory use April 1, 2014.
Cms /hcfa 1500 Claim Form (new 02/12) Version 500 Sheets ...
Understand the difference between the outdated hcfa 1500 form and the CMS 1500 claim form. Why the form was changed and when...
Hcfa 1500 Electronic Claim Forms | Medical Billing ...
Fill out hcfa-1500 (CMS 1500) forms on your computer and print the data; IMPORTANT newS - hcfa-1500 (02/12) Release ; Simple interface with boxes for ease of use and ... : Cms 1500 Claim Forms - Hcfa (version 08/05 ...
Claim forms Plus allows you to order CMS 1500 claim forms, which replaced the hcfa 1500 claim forms, online. This is the 08/05 version. Order hcfa 1500 claim forms.
Cms 1500 Claim Forms And Hcfa 1500 Claim Forms
Following are the important highlights of changes in new hcfa for 2014. Scanable reading QR code is introduced that is replacement of the symbol 1500
Hcfa 1500 Medical Insurance Claim Form > Medical Billing ...
CMS 1500 claim forms - hcfa (Version 08/05) (500 Sheets; Laser/Inkjet Printer)
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06 04

To: All Providers Managed Care Organizations Memorandum No:

06-04 Issued: February 6, 2006

From: Douglas Porter, Assistant Secretary

Health and Recovery Services Administration (HRSA) For information, contact: 800.562.3022

Subject: Update HCFA-1500 Claim Form Instructions and page updates for the General Information Booklet.

The Health and Recovery Services Administration (HRSA) has updated the instructions for completing paper copies of the HCFA-1500/CMS-1500 and is adding a new section to the General Information booklet on How to Complete a HCFA .

Claim Form (HCFA-1500 or CMS-1500)


The Health Insurance Claim Form is now officially called -Providers can order and purchase --forms

on-line from many office supply stores.

Because HRSA billing instructions still refer to -, HRSA will continue to u- - until all of the billing instructions are updated.

HRSA uses Optical Character Recognition (OCR) equipment to process paper claim forms.

Use only the original pre-printed red and white CMS-1500 claim forms (version 12/90 or later, preferable on 20# paper).

The CMS-1500 form is designed specifically for OCR systems.

The scanner does not read black and white (copied, carbon, or laser-printer generated) CMS-1500 claim forms.

Most of HRSAs billing instructions include -section.

HRSA periodically revises this section according to ongoing system changes.

This memorandum introduces a number of updates to this section for certain fields on the claim form.

HRSA will incorporate these updates into specific program billing instructions as these billing instructions are reviewed and revised.

in addition to those below for completing the HCFA-1500 or CMS-1500 form for your specific program.Numbered Memorandum 06-04

February 6, 2006 Page 2

Updated Claim Form Fields

Field 17a ID Number of Referring Physician

If a referring provider does not have an HRSA-assigned ID number, enter 8900946 into Field 17a.

Use this standard number only for referring providers who are non-Medicaid referring providers.

Providers can find more information by visiting the Provider Number Reference web site: 19 Reserved for Local Use

Use Field 19 for comments that require a claims specialist to review a claim before payment is made.

Inappropriate comments in this field may result in delayed processing of claims.

Examples of appropriate comments include the following:


A or B;

A, triplet B, or C;

ITA client;

National Drug Codes); and

Backup .

Field 24D Procedures, Services, or Supplies CPT/HCPCS

When appropriate, providers enter a modifier in this Field 24D
new hcfa 1500 claim form

If there is more than one modifier, list them in descending numerical order.

For 24E Diagnosis Code

Enter the valid ICD-9-CM diagnosis code exactly as shown in the current volume of the ICD-9-CM manual, or relate each line item to Field 21 by entering a 1, 2, 3, or 4.

Enter the principal diagnosis as the first diagnosis code.

Providers must follow additional digital requirements found in the ICD-9-CM manual.Numbered Memorandum 06-04

January 30, 2006 Page 3

Field 26 - Patient Account Number

Providers create this number.

HRSA prints the characters entered in Field 26 on Remittance and Status Report (RA) under the heading Patient Account Number.

If providers use symbols in Field 26 (on paper or electronic claims) this may invalidate an electronic RA.

To ensure correct processing of an electronic RA, do not use spaces or the following characters in Field 26:


(asterisk) ~

(tilde) :


Field 30 Balance Due

Calculating the estimated payment due:

Results in faster adjudication and fewer rebilled claims; and

Aligns HRSA-party payers.

HRSA automatically calculates the estimated payment due for physician, dental, and institutional claims (excluding Medicare crossover claims).

HRSA calculates this amount on both electronic and paper claims.

This calculation takes place when the estimated payment due is either missing or not calculated correctly on the claim form and providers indicate one of the following:

Third-party payments;

Patient spenddown (if applicable); and

Noncovered charges on the claim form.

Providers must indicate the total charges on the claim and use the claim form specified in the nstructions.

Place only six detail lines on each claim form.

HRSA claim forms.

If more than six detail lines are needed, use additional claim forms.

Total each claim form separately.

Do not indicate the entire total (for all claims) on the

If the provider does not include or miscalculates the total charges on the claim form, HRSA will deny the claim.

Numbered Memorandum 06-04

January 30, 2006 Page 4

Field 33 - PIN #

HRSA assigns this 7-digit number to identify the performing individual (e.g., the physician or Advanced Registered Nurse Practitioner who performed the service) when the individual is part of a group, such as a clinic, which has its own assigned provider numbers for billing purposes.

General Information Booklet New Replacement Pages

Attached are updated and new General Information Booklet pages i - iv and H.11-H.18.

How do I conduct business electronically with HRSA?

You may conduct business electronically with HRSA by accessing the WAMedWeb at can I get HRSA provider issuances?

To obtain DSHS/HRSA provider numbered memoranda and billing instruction, go to the DSHS/HRSA website at (click the Billing Inst
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