Types of HCFA Claim Bills

The HCFA, or Health Care Financing Administration, is now known as CMS, Centers for Medicare and Medicaid Services. A claim is the bill for services rendered to the insured. This claim is sent from the health care provider to a CMS claims-processing center, which checks claim correctness and pays properly.



There are many types of HCFA claim bills. Most are for the health care provider's use.

Forms may be used by health care providers, health care facilities, beneficiaries and interested third-parties.

Health Care Provider Use Forms

• These forms are used by health care providers and are submitted to CMS, Centers for Medicare and Medicaid Services. Skilled nursing facility, nursing facility and rehabilitation forms are used by SNFS, NSF and rehabilitation facilities for reporting purposes, eligibility of patients and adverse actions. Ambulatory surgical center forms are used by ASCs for reporting purposes and patient eligibility. Enrollment forms are used by physicians, health care providers and facilities to enroll in the Medicare and Medicaid programs. Attending physician use forms are used by attending physicians for the purposes of planning treatment, patient evaluations and Medicare emergencies. Medical necessity forms are used to detail medical necessity of procedures, medicines and durable medical equipment such as wheelchairs and crutches. Clinical laboratory use forms are used by laboratories for reporting purposes and to document adverse actions. Noncoverage forms detail noncoverage of benefits. Durable medical equipment forms are used to request durable medical equipment such as wheelchairs, crutches and special footwear. Home health agency forms are used by home health agencies for reporting purposes. Notice of denial forms are used to inform health care providers of denials in coverage for an insured. Notice of exclusions forms explain exclusions to health care coverage. Plan of treatment forms are used by health care providers to plan a course of treatment for a patient. Psychiatric criteria forms are used by psychiatric personnel to assess the mental health of patients. Quality of life assessment forms are used by skilled nursing facilities and rehabilitation facilities to assess the quality of life of a patient. Request forms (cancellations, verification of certification, medical necessity, hearings, information, validation, eligibility) are used by health care providers to request information from CMS. Responsibilities forms are used by CMS to inform health care providers of their responsibilities when dealing with certain situations such as emergency cases. Billing forms are used by health care providers to submit claims to CMS for the purposes of getting reimbursement for services rendered to an insured patient. Dispute forms are used by health care providers to dispute a claim denial from CMS. Third-party billing forms are used by third-party billers, such as other insurance companies and other facilities who are not contracted with CMS as Medicare or Medicaid providers, to submit claims for reimbursement for services rendered to an insured patient. Consent forms are used by the health care providers to explain and receive full informed consent from the insured for a service or procedure.

Beneficiary Forms

• These are forms filled out by the beneficiary (insured). Authorization forms are used to authorize payment to the health care provider and release of information on the beneficiary. Beneficiary forms are used to enroll in Medicare or Medicaid and to enroll in special programs under Medicare or Medicaid. Complaint forms are used to register an official complaint about a health care provider or facility. Retiree drug subsidy forms are used to apply for subsidized help for prescription drug costs.

Internal Data Forms

• Internal data forms are used for the collecting data on providers, facilities and beneficiaries for the purposes of improving the quality of care. Addendum forms are sent between health care providers and CMS to make notice of changes to previous forms. Internal data collection forms are used between health care providers/facilities and CMS for the purpose of collecting and analyzing data on Medicare and Medicaid recipients, facilities and providers. Facility survey forms are used to survey facilities enrolled in Medicare and Medicaid to ensure compliance with federal and state laws.