How to File CMS-1500 Forms for UHC & AmeriChoice

UnitedHealthcare and AmeriChoice health insurance providers use Form CMS-1500 supplied by the Center of Medicare and Medicaid Services. CMS-1500 forms allow billers to file patient claims to receive benefit payments. The form requires information regarding the patient, the insured person, the health insurance provider and the physician or health care provider who rendered the service.

Instructions

Patient Section

• 1

  Obtain Form CMS-1500 from your health care provider, by contacting the United States Printing Office at 202-512-0455 or at http://www.cms.hhs.gov/CMSForms. Using dark ink, fill in the patient's name, address and telephone number on lines 2, 5 and 6. Provide the date of birth on line 3 along with the patient's gender.

• 2

  Check the appropriate box on line 6 representing the patient's relationship to the insured: self, spouse, parent or other. Indicate the patient's marital and employment/student status in box 8.

• 3

  Mark the space on line 10 if the reason for treatment stemmed from an incident at the patient's place of employment, an auto accident or some other accident. Indicate the state where the incident or accident took place. Have the patient sign and date the form. If the patient is incapable of signing, the person completing the form may sign.

Insured Section

• 4

  Provide the identification number of the insured person on line 1a and indicate if the patient is the insured person or someone else. Write the insured person's name on line 4 and his or her address and telephone number on line 7.

• 5

  Write in the insured person's policy information on line 11. This consists of the policy group or FECA number. Include the insured person's date of birth and gender in subcategories 11a and 11b.

• 6

  Provide the employer's plan name on line 11c. Indicate whether the insured person has any other health insurance benefits. Complete any information for a second insurer on line 9.

• 7

  Have the insured person sign and date the form.

Provider Section

• 8

  Write in the referred provider's name on line 17 and his or her NPI number on line 17a. Fill in the referred provider's address and telephone number on line 33.

• 9

  Write in the name of the facility where the medical service was provided on line 24. Indicate the dates and types of services in the spaces below line 24.

• 10

  Write in the charges on line 28.

• 11

  Have the health care provider sign and date the form. Include information about the facility and the NPI code. The health care provider will then submit the form.