Cms 1500 pdf 02-12-01x

Thank you for helping us to process your claims efficiently and accurately. Claims must be made within 12 months after services are provided. A federal government website managed and paid for by the u. Instructions for completing the cms 1500 claim form the center of medicaid and medicare services cms form 1500 must be used to bill sfhp for medical services. Instructions for completing the cms 1500 claim form. Claim committees 1500 claim form instruction manual at blue cross and blue shield of oklahoma offers this guide to help you complete the cms 1500 0212 form for your patients with blueshield coverage. Omb approved the revised cms1500 paper claim form, known as omb09381197 form 1500 0212. Authority to collect information is in section 205a, 1862, 1872 and 1874 of the social security act as amended, 42 cfr 411. If the master form cms 1500 does not align to your printer, click the green down arrow icon labeled create a similar form. Enter up to 12 diagnosis codes selecting either icd9 or.

Download cms claim form 1500 which is used by health care professionals to bill medicare and medicaid. Free fillable cms medical claim form 1500 template with. Reference instruction manual for form version 0212. A federal government website managed and paid for by.

Starting april 1, 2014 only the revised, 0212 version will be accepted. The form is used by physicians and allied health professionals to submit claims for medical services. Aligning the cms 1500 form for one or more printers. The current version of the original manual from the national uniform claim comettee of how to complete the cms1500 claim form. We are authorized by cms, champus and owcp to ask you for information needed in the administration of the medicare, champus, feca, and black lung programs. All items must be completed unless otherwise noted in these instructions. In addition to medicare parts ab and for medicare durable medical equipment administrative contractors.