HFCA Form 1500 Instructions for Palmetto

Palmetto GBA has been one of the largest administrators of Medicare health insurance since the 1960s. The HFCA 1500 form is the official standard form used by providers to submit claims for reimbursement by Medicare, Medicaid, and supplementary insurance companies like Palmetto GBA. These forms can be very confusing for the average policy holder, but if you gather all your policy documents before you begin and enlist the help of your provider, filling out claims forms like the HFCA 1500 does not have to be difficult.

Things You'll Need

• HFAC 1500 claim form
• Blue or black pen

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Instructions

• 1

  Fill in the box corresponding to the type of healthcare coverage applicable to the claim. If this is a Medicaid claim, mark the Medicaid box then write in the insured's ID number, the patient's Heath Insurance Claim Number (HICN).

• 2

  Fill in the patient's personal information. Write in the patient's name, birth date, sex, address and telephone number exactly as it appears on his Medicare card.

• 3

  Provide the requested information about the insured party if the patient is not the policy holder. If Medicare is the patient's primary insurance, leave item number 4 and 6 blank. If the patient has medical insurance primary to Medicare, fill in the name of the insured.

• 4

  Indicate the patient's relationship to the insured by marking the appropriate box. Provide the information requested about the patient's insurance primary to Medicare by filling in item 7 with the contact information for the insured and by filling out item number 11 with the insured's policy information.

• 5

  Fill in items 8 and 10 to indicate the patient's marital status and to indicate whether the injury was job-related, auto accident-related, or related to some other kind of accident.

• 6

  Ask your provider to fill in items 9a through 9d with the patient's Medigap benefit information. The provider should also fill in the insured's policy/group number, the date of birth and sex, and provide the claim's processing address of the Medigap insurer in box 9c and the Payer ID number in box 9d.

• 7

  Sign and date the form in box 12 with your complete name and a 6 or 8 digit date. If the patient is unable to sign the form, a representative may sign on the patient's behalf. The patient or representative must also provide a signature in box 13 giving permission for Medigap benefits to be paid to the provider or supplier.

• 8

  Provide information about the current illness or injury in items 14 and 16. Fill in the date of the current injury, illness, or pregnancy and, if the patient is employed, the dates during which the injury will prevent him from returning to work.

• 9

  Fill in the provider's name in item 17. In box 17a, have the provider fill in his or her UPIN and, in box 17b, his NPI. These fields must be completed if the provider orders a service.

• 10

  Provide the requested information about the patient's hospitalization in items 18 through 20. In item 18, indicate the dates of any hospital stay related to the current illness or injury and, in item 20, note whether an outside lab was used for diagnostic tests.

• 11

  Have the provider fill out item 24 with all the necessary information regarding services rendered and the charges for those services. The provider must indicate the dates and place of service, relevant procedure codes and diagnosis code reference numbers, charges for services, days or units, ID qualifiers, and the UPIN/NPI of rendered physicians.

• 12

  Ask your provider to fill in item 25 with the Federal Tax ID number or social security number and indicate which number is being used by marking the appropriate box.

• 13

  Have the provider fill out items 27 through 30 with relevant billing information. In item 27 the provider must indicate that he accepts Medicare benefits. Item 28 must be filled in with the total charge for services, item 29 with the amount the patient paid for those services, and item 30 with the balance due.

• 14

  Ask the provider to sign and date the form under item 31 and, in 33, ask her to provide her telephone number, billing name, address, and zip code as well as the provider's NPI in item 33a.