Get the free Revised CMS 1500 Paper Claim Form: Version 02/12

Revised CMS 1500 Paper Claim Form: Version 02×12 Prognosis Version V3B1, release date March End supports Revised CMS1500 Paper Claim Form: Version 02×12. Kindly purchase the new APPROVED OMB 09381197

How to fill out revised cms 1500 paper

How to fill out revised cms 1500 paper:

1. Begin by entering the patient's information in Box 1. This includes their full name, address, and date of birth.
2. Move on to Box 2, where you will input the patient's unique identification number. This can be their social security number or a specific identifier assigned by the healthcare provider.
3. In Box 3, indicate the patient's date of birth, using the MM/DD/YYYY format.
4. Proceed to Box 4 and fill in the patient's sex - either male (M) or female (F).
5. Box 5 requires you to indicate the patient's marital status, specifying whether they are single (S), married (M), divorced (D), widowed (W), or legally separated (L). If none of these options apply, you can use the code U for unknown.
6. In Box 8, you'll enter the patient's employer's name, if applicable. If the patient has no employer, simply write "None".
7. Moving to Box 10, provide the patient's address, including the street, city, state, and ZIP code.
8. Box 11 requires you to indicate whether the patient has other health insurance coverage. If they do, fill in the respective information in Box 11a-e. If not, mark "No" in Box 11.
9. In Box 14, you'll input the date of the current illness, injury, or pregnancy in the MM/DD/YYYY format.
10. In Box 17, you'll identify the referring or ordering provider, including their name, address, and unique identifier.
11. Moving to Box 21, indicate the diagnosis or nature of illness or injury. Use specific codes from the International Classification of Diseases (ICD) manual to accurately describe the condition.
12. In Box 24e, you'll enter the dates of service for each procedure or treatment provided, using the MM/DD/YYYY format.
13. Box 24f requires you to input the appropriate procedure or treatment codes. Use Current Procedural Terminology (CPT) codes to indicate the services rendered.
14. Finally, review the completed CMS 1500 form for accuracy before submitting it to the insurance provider.

Who needs revised cms 1500 paper:

1. Healthcare professionals who offer services covered by insurance.
2. Medical billing and coding staff responsible for submitting claims to insurance companies.
3. Hospitals, clinics, and independent healthcare providers who handle insurance claims on behalf of their patients.

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