How to Fill Out CMS HCFA 1500 Forms

Medical billing is a lucrative business that can be done from home. The CMS HCFA 1500 claim form is the approved form for use by physicians, physical therapists and facilities such as durable medical equipment companies to inform insurance companies of services or products received by patients. You will be able to file an insurance claim if you carefully follow the steps. Most steps are self-explanatory, but some require explanation.

Things You'll Need

• CMS HCFA 1500 software
• 2010 ICD - 9 CM Code book
• 2010 CPT Code book

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Instructions

• 1

  Type an x in the box next to the insurance you will be billing in box 1.

• 2

  Enter the insurance identification number for the policy holder in box 1a. The policy holder is the person whose name is on the insurance card.

• 3

  Type names in this way: last name, first name.

• 4

  Enter any other policyholder information in box 9. A patient might have secondary coverage from a parent, spouse or himself. Complete boxes 9a through 9d with the secondary policy holder's information. If there is no secondary insurance, leave this section blank.

• 5

  Type an x in the boxes in section 10 to select yes or no if the claim is accident related. If the patient's claim is not accident related, select "No" for all options.

• 6

  Enter SOF, or signature on file, in boxes 12 and 13, as long as the patient has signed the consent form to share her information with the insurance company you are billing. You need to be able to provide proof of the signatures in the event you are audited.

• 7

  Enter the date of the accident or the date the patient became ill, in box 14. Box 14 needs to be completed only if the illness or injury pertains to the services the patient received.

• 8

  Fill out box 15 if the insurance company needs to know when the patient had been ill with the illness indicated in box 14.

• 9

  Enter the "to and from" dates when the patient will be out of work in box 16. This section of the form is for Workman's Compensation claims.

• 10

  Enter the doctor who referred the patient in box 17. Box 17a is for the doctor's UPIN, or Unique Provider Identifier. Box 17b is reserved for the National Provider Identifier, or NPI.

• 11

  Select "Yes" if labs were done outside your office, and indicate in box 20 the amount that needs to be reimbursed.

• 12

  Enter up to four diagnosis codes in box 21. The physician will indicate diagnosis information, but you may be required to look up the codes in your ICD-9 code book.

• 13

  Enter information in box 22 only if you are billing Medicaid. Reference numbers will be provided by Medicaid.

• 14

  Enter any authorization numbers in box 23. If a service or product requires authorization beforehand, the insurance company would need to have been notified and would provide you with an authorization number if approved.

• 15

  Enter the "to and from" dates the patient received services or products in the spaces below box 24a.

• 16

  Enter the place of service under box 24b. Each place of service is represented by a two-digit number.

• 17

  Indicate if the service was an emergency by typing a Y for yes or an N for no under box 24c.

• 18

  Enter the CPT (or Current Procedural Terminology, according to the American Medical Association), in box 24d. Look up the CPT code for the product or service you provided to your patient. Include any modifiers for the CPT code, such as procedures done to the right side of the body. A list of modifiers should be included in your CPT code book.

• 19

  Enter a 1, 2, 3 or 4 under box 24e to indicate the diagnosis you listed in box 21 that pertains to the procedure code.

• 20

  Enter the charges for the service or procedure in box 24f. Enter the quantity of services or products under box 24g. Skipping to box 24j, enter the product or service provider's NPI number.

• 21

  Enter the tax identification of the billing provider, and select EIN in box 25. Skip box 26 unless you need a reference for yourself.

• 22

  Always select "yes" to accept assignment for box 27.

• 23

  Enter the total charges you are billing for in box 28; any charges that had been paid will be listed in box 29, and the remaining total will be listed in box 30.

• 24

  Have the physician or provider sign in box 31, enter the name and address of the patient received services or products in box 32, and include the NPI in box 32a. Enter the provider or facility submitting the claim in box 33, and include the NPI in box 33a.