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The Revised CMS-1500 Form at a Glance The National Uniform Claim Committee (NCC) has approved a revised CMS-1500 health insurance claim form (version 02/12) to replace the current form (version 08/05).

How to fill out the revised cms-1500 form

How to fill out the revised CMS-1500 form:

1. Begin by entering the date at the top right corner of the form.
2. Fill in the patient's personal information, including their full name, address, date of birth, and gender.
3. Next, provide the patient's insurance information, such as their policy number, group number, and the insured's name if different.
4. Indicate the patient's relationship to the insured, whether they are the subscriber (policyholder), a spouse, or a dependent.
5. Specify the patient's employment status and whether the visit is related to an accident, injury, or illness.
6. In the section for the insured's information, provide their full name, address, and date of birth.
7. If there is secondary insurance coverage, fill in the necessary information in the appropriate section.
8. Enter the healthcare provider's information, including their name, address, and phone number.
9. Indicate the patient's condition or diagnosis using the appropriate codes from the ICD-10 code set.
10. In the "Procedures, Services, or Supplies" section, list the services provided by the healthcare provider. Include the corresponding procedure code, date of service, place of service, and the charges for each service.
11. If any referrals were made, provide the referring provider's name, NPI number, and the date of the referral.
12. Sign and date the form once you have completed all the necessary information.
13. Keep a copy of the form for your records and submit the original to the insurance company for reimbursement.

Who needs the revised CMS-1500 form:

1. Medical practitioners and healthcare providers who bill for their services using the CMS-1500 form need the revised version.
2. Health insurance companies and third-party administrators require the revised CMS-1500 form to process and reimburse medical claims.
3. Patients who are covered by health insurance and seek reimbursement for medical expenses also need the revised CMS-1500 form to submit their claims.

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What is the revised cms-1500 form?

The revised CMS-1500 form is the standard claim form used by health care professionals to bill Medicare and Medicaid for services provided.

Who is required to file the revised cms-1500 form?

Health care professionals who provide services covered by Medicare and Medicaid are required to file the revised CMS-1500 form.

How to fill out the revised cms-1500 form?

Health care professionals must accurately fill out the CMS-1500 form with patient information, services provided, and diagnosis codes.

What is the purpose of the revised cms-1500 form?

The purpose of the CMS-1500 form is to request reimbursement from Medicare and Medicaid for medical services provided to patients.

What information must be reported on the revised cms-1500 form?

Information such as patient demographics, provider information, service codes, and diagnosis codes must be reported on the revised CMS-1500 form.