Get the free 3214 FORM HCFA-1728-94 06-01 3214 WORKSHEET B - COST

3214 3214. FORM HCFA172894 0601 WORKSHEET B COST ALLOCATION GENERAL SERVICE COSTS AND WORKSHEET B1 COST ALLOCATION STATISTICAL BASIS Worksheet B provides for the allocation of the expenses of each

How to fill out 3214 form hcfa-1728-94 06-01

1. To fill out the 3214 form hcfa-1728-94 06-01, start by entering the date in the designated space on the top right corner of the form. Make sure to use the format specified on the form.
2. Under the "Patient Information" section, provide the patient's full name, address, and date of birth. Additionally, include the patient's Medicare Health Insurance Claim Number (HICN) or the Social Security Number (SSN).
3. In the "Provider Information" section, enter the Provider Transaction Access Number (PTAN), which is a unique identifier for the billing provider. Also, fill in the NPI (National Provider Identifier) and the provider's name, address, and telephone number.
4. Next, move on to the "Claim Information" section. Provide the patient's insurance policy or group number, along with the effective date of coverage. If the patient has other coverage, specify it in the designated space.
5. In the "Admission and Discharge Dates" section, enter the dates of the patient's hospital admission and discharge. Ensure that the dates are accurate and in the required format.
6. Now, detail the services provided to the patient in the "Statement Covers Period" section. Provide the dates of service, along with a thorough description of the services rendered. Include the appropriate codes, modifiers, and charges for each service.
7. If the patient received any supplies, drugs, or other items during their treatment, describe them in the "Items Provided or Services Rendered" section. Include the dates, descriptions, quantities, and charges for each item.
8. Towards the bottom of the form, there is a section for the "Billing Provider's Information and Certification." Fill in this section, including the provider's name, signature, and date signed.
9. Finally, review the completed form to ensure all information is accurate and complete. Make a copy for your records and submit the original form to the appropriate organization or insurance company.

As for who needs the 3214 form hcfa-1728-94 06-01, it is primarily used by healthcare providers, such as hospitals and medical facilities, to submit claims for reimbursement to Medicare or other insurance companies. This form ensures that the provider is properly compensated for the services rendered to the patient.

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What is 3214 form hcfa-1728-94 06-01?

3214 form hcfa-1728-94 06-01 is a form used for reporting healthcare claims.

Who is required to file 3214 form hcfa-1728-94 06-01?

Healthcare providers and facilities are required to file 3214 form hcfa-1728-94 06-01.

How to fill out 3214 form hcfa-1728-94 06-01?

To fill out the form, you need to provide detailed information about the healthcare services provided.

What is the purpose of 3214 form hcfa-1728-94 06-01?

The purpose of the form is to document and bill for healthcare services.

What information must be reported on 3214 form hcfa-1728-94 06-01?

The form requires information such as patient details, services provided, and healthcare provider information.