How to Fill Out an HCFA Claim

The HFCA 1500 form, now referred to as the CMS 1500, is the standard form used by health providers seeking payment for medical services rendered to patients. An insurance company can deny payment if you don't fill the HCFA 1500 form out properly. Incomplete information also leads to delays in payment processing. Medical billers receive training on how to fill out the HCFA form to avoid any issues. You'll improve your medical billing efficiency once you become familiar with the form.

Things You'll Need

• Patient medical record
• Patient medical condition
• Patient and/or insured's signature
• Authorization number
• Physician signature
• Federal tax identification number
• Procedure codes
• Charge amount
• Balance due
• Patient co-payment information
• Provider billing address

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Instructions

• 1

  Use the patient's medical records to fill out HCFA 1500 form. In box 1, select the appropriate medical coverage (Medicare, Medicaid, Champus, ChampVa, Group Health Plan or FECA Black Lung). Enter the patient's name, date of birth, gender, residential address, relationship to the insured, group or policy number, insurance plan, employment status and employer information and marital status. Check the appropriate box if the patient is a full- or part-time student. Check Yes or No if the patient's medical condition is the result of an employment, auto, or other accident. Also list the state in which the accident took place.

• 2

  Enter the insured's information if the patient has coverage under another person. This includes the insured's ID number, residential address, policy number or Federal Employees' Compensation Act (FECA) number, date of birth and gender. Enter the employer name or school name if insurance is through a school, the insurance plan or program name. Check either yes or no if the insured has another health benefit plan.

• 3

  Obtain the patient's or authorized person's signature including the date.

• 4

  Enter the dates when the patient was unable to work, including hospitalization dates caused by the illness or injury. Check either yes or no if the patient visited an outside lab and include any charges. If the patient used Medicaid, enter the Medicaid resubmission code, original reference number and prior authorization number. Call the phone number on the insurance card to obtain information regarding prior medical authorization.

• 5

  Input the onset date of illness or injury, as well as the date of prior or similar symptoms. List the name of the referring physician including the physician's ID number.

• 6

  Refer to your ICD9 medical coding handbook to enter the appropriate diagnosis codes.

• 7

  Enter the physician's federal tax ID number or social security number along with the patient's account number. Check yes or no in the "Accept Assignment" box.

• 8

  Enter the total charge for health services, amount paid by the patient and balance due. The balance due is usually the patient's co-payment. For example, if the insurance company pays 80 percent of the medical bill, the patient has a 20 percent co-payment.

• 9

  Obtain the dated signature of the treating physician or care giver. Enter the name and address of the health facility used to provide the service. Include the physician or health provider's billing name, address and phone number. You can put "SAME" if both the facility address and billing address are the same.