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This document serves as a reference guide for providers to complete the CMS-1500 claim form for mental health and substance abuse services, detailing instructions for filling out each section of the

How to fill out cms-1500 claim form completion

How to fill out CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers

1. Obtain the CMS-1500 Claim Form, which can be downloaded or ordered from the appropriate governing body.
2. Fill out the patient's information in Field 1, including the insured's policy number and the group number, if applicable.
3. In Field 2, enter the patient's name.
4. Complete Field 3 with the patient's date of birth and gender.
5. In Fields 4 and 5, enter the insured's name and relationship to the patient.
6. Fill out Fields 6 and 7 with the patient's address and phone number.
7. In Field 8, indicate whether the patient is a student or if there are other health insurance policies.
8. Complete Fields 9a-b to indicate the other insurance, if applicable.
9. In Field 10, specify the reason for the visit or the diagnosis.
10. Fill out Fields 11, 12, and 13 with the referring provider's information and authorization if needed.
11. In Fields 14-24, list the procedures performed and their corresponding codes along with the dates of service.
12. Complete Fields 25-33 with the provider and facility details, including NPI numbers and tax ID.
13. Review the entire form for accuracy and clarity before submitting.

Who needs CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

1. Mental health and substance abuse providers who wish to file claims for reimbursement for services rendered.
2. Healthcare professionals working with patients who are eligible for PROMISe™ services under state programs.
3. Billing personnel within mental health facilities that handle claims processing for services provided.

People Also Ask about

Can I print my own CMS 1500?

The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form.

Where can I get CMS 1500 forms?

In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).

Can I handwrite a CMS 1500 form?

Can CMS 1500 Forms be Handwritten? While it is technically possible to handwrite a CMS 1500 form, it is generally not recommended.

How to print a health insurance claim form?

Printing your CMS 1500 form Open the claim. Click the download icon. Select Download complete form if you want to generate the full, red CMS 1500 form as a PDF. Select Download field entries only if you want to only generate the data fields so you can print it onto a blank CMS 1500 form.

How do I print text only in CMS 1500?

Open the local file with your system's PDF reader. Navigate to “Save and Print Options” and select Print Text Only.

Who completes the CMS 1500 claim form?

The common paper claim form used by suppliers and healthcare providers to bill Medicare and Medicaid is the CMS 1500 form, sometimes known as the HCFA 1500 form. This form, which serves as a thorough document that carefully details the services provided to patients, is crucial to the healthcare reimbursement system.

For pdfFiller’s FAQs

What is CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers refers to the standardized procedure for filling out the CMS-1500 form, which is used to submit claims for reimbursement for services rendered in the fields of mental health and substance abuse.

Who is required to file CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

Mental health and substance abuse providers who are enrolled in the PROMISe™ system and wish to bill for their services must complete and submit the CMS-1500 Claim Form.

How to fill out CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

To fill out the CMS-1500 Claim Form for PROMISe™, providers should carefully enter patient and service information, including patient identification, diagnosis codes, procedure codes, and the provider's details, in accordance with PROMISe™ guidelines.

What is the purpose of CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

The purpose of completing the CMS-1500 Claim Form is to ensure accurate billing for mental health and substance abuse services provided, facilitating timely reimbursement from insurance programs through the PROMISe™ system.

What information must be reported on CMS-1500 Claim Form Completion for PROMISe™ Mental Health & Substance Abuse Providers?

The information that must be reported includes the patient's demographic information, service dates, procedure codes, place of service, billing provider details, and any applicable diagnosis codes.