Get the free 837 Professional CMS 1500 claim form - eohhs.ri.gov - eohhs ri

Rhode Island Medicaid 837 Professional CMS 1500 claim form This document is a field by field instructional help sheet. The fields are listed in a left to right format as they appear in the Provider

How to fill out 837 professional cms 1500

How to fill out 837 professional cms 1500

1. Start by gathering the necessary information: You will need the patient's demographic information, insurance details, and specific details about the medical services provided.
2. Begin filling out the top portion of the form: Enter the patient's name, address, and contact information, as well as their insurance information.
3. Fill out the claim information: Provide the patient's birth date, gender, and relationship to the insured. Indicate whether the claim is for a specific condition or injury and include the date of the injury or onset of symptoms.
4. Include the billing provider information: Enter the name, address, and contact information of the healthcare provider submitting the claim.
5. Specify the primary insurance information: If the patient has primary insurance coverage, indicate the details of the primary insurance provider, including the policy number and group number.
6. Provide information on any other insurance coverage: If the patient has secondary or tertiary insurance coverage, include the details of these insurance providers.
7. Fill out the diagnosis information: Enter the ICD-10 codes for the patient's diagnosis or condition. Include any additional diagnoses or relevant information.
8. Complete the procedure information: Provide the appropriate CPT codes for the medical services rendered. Include the date of service and any modifiers as necessary.
9. Indicate the charges for each service: Enter the charge amount for each procedure performed, including any applicable discounts or adjustments.
10. Include any additional documentation: If there are any supporting documents or attachments required, make sure to include them with the completed form.

Who needs 837 professional cms 1500?

1. Healthcare providers: The 837 professional cms 1500 form is typically used by healthcare providers, such as physicians, chiropractors, physical therapists, or any other healthcare professional who needs to submit claims for their services.
2. Insurance companies: Insurance companies require the completed 837 professional cms 1500 form in order to process and reimburse healthcare providers for the services rendered to their insured members.
3. Patients: While patients themselves may not directly fill out the form, they need to ensure that their healthcare providers accurately complete it, as it is used to bill insurance companies and determine their financial responsibility for the services provided.

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