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012114 N EW S BLAST (Update from 120413) REVISED 1500 CLAIM FORM USAGE TRANSITION BEGINS JANUARY 2014 The National Uniform Claim Committee (NCC) has announced the approval of the timeline for transitioning

How to fill out revised 1500 claim form

How to fill out the revised 1500 claim form:

1. Start by entering the patient's information in box 1, including their name, address, and insurance policy number.
2. In box 2, provide the patient's date of birth and gender.
3. Box 3 should be filled out with the patient's telephone number, ensuring it is a number where they can be easily reached.
4. Proceed to box 4 and enter the name and address of the policyholder, if different from the patient.
5. If applicable, indicate any other health insurance coverage in box 5.
6. In box 6, provide the patient's relationship to the insured, such as self, spouse, child, or other.
7. Box 7 requires the insured's address if different from the patient's or policyholder's address.
8. Next, enter the patient's unique identification number in box 8, also known as the Medical Record Number (MRN).
9. If the patient has another identification number, such as a social security number, it should be indicated in box 9.
10. Box 10a should contain the patient's date of onset or injury.
11. If it is an accident or has a related illness, specify the state in which it occurred in box 10b.
12. In boxes 11-18, provide the patient's insurance information, including the policy or group number, plan or program name, and whether the claim is for auto accident, employment-related, or other accident.
13. Moving on to boxes 19-24, describe any additional insurance information, such as the primary insurance policyholder's name and address, as well as any other relevant information.
14. In box 25, indicate the provider's federal tax ID number or Social Security number.
15. Box 26 requires the provider's NPI (National Provider Identifier) number.
16. Fill in the provider's billing name, address, city, state, and zip code in boxes 27-33.
17. Box 33a should be used to specify the provider's group or clinic, if applicable.
18. Provide the service facility information in boxes 32-33b, including the name, address, city, state, and zip code.
19. Moving on to the procedure and diagnosis information, fill in boxes 24-28 with the corresponding codes.
20. In box 29, indicate the total charges for the services rendered.
21. Box 30 requires the amount paid, while box 31 should contain the balance due.
22. Check the appropriate box in box 32 to indicate whether the patient has been referred to another provider or if there are any withholding or limitations on their records.
23. Lastly, ensure that all necessary signatures and dates are filled in, including the provider's and patient's signatures.

Who needs the revised 1500 claim form?

1. Medical providers such as doctors, dentists, hospitals, and clinics who bill insurance companies for their services need the revised 1500 claim form.
2. Insurance companies require the revised 1500 claim form to process and evaluate medical claims submitted by healthcare providers.
3. Patients who receive medical services and wish to file a claim for reimbursement may need the revised 1500 claim form to provide the necessary information to their insurance company.

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What is revised 1500 claim form?

The revised 1500 claim form is a standard form used by healthcare providers to bill insurance carriers for their services.

Who is required to file revised 1500 claim form?

Any healthcare provider who wants to seek reimbursement for their services from an insurance carrier is required to file the revised 1500 claim form.

How to fill out revised 1500 claim form?

To fill out the revised 1500 claim form, healthcare providers need to provide information such as patient demographics, insurance information, diagnosis codes, procedure codes, and the services provided. It is important to accurately complete all the required fields.

What is the purpose of revised 1500 claim form?

The purpose of the revised 1500 claim form is to facilitate the billing and reimbursement process between healthcare providers and insurance carriers. It allows healthcare providers to receive payment for the services they have rendered.

What information must be reported on revised 1500 claim form?

The revised 1500 claim form requires reporting of information such as patient demographics, insurance information, diagnosis codes, procedure codes, and the services provided by the healthcare provider.