Clinics and Other Outpatient Facility Services Handbook - TMHP

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013
OP.10
Renal Dialysis CMS-1500 Example
1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
MEDICAID OF TX
PO BOX 20055
AUSTIN, TX 78720-0555
PICA
CARRIER
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP
FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS
HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)
x 123456789
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE SEX
MM DD YY
Doe, Jane 02 02 1971 M
F x
5. PATIENT’S ADDRESS (No., Street)
341 Tosca Way x
CITY
STATE 8. PATIENT STATUS
Houston TX Single Married Other x
ZIP CODE TELEPHONE (Include Area Code)
( )
12345 123 555-1234
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
MM DD YY
M
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
SEX
F
6. PATIENT RELATIONSHIP TO INSURED
Self Spouse Child Other
Full-Time Part-Time
Employed Student Student
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
YES NO
YES NO
YES NO
10d. RESERVED FOR LOCAL USE
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
x
x
x
PLACE (State)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY
STATE
ZIP CODE TELEPHONE (Include Area Code)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
MM DD YY
b. EMPLOYER’S NAME OR SCHOOL NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO
( )
c. INSURANCE PLAN NAME OR PROGRAM NAME
x
SEX
M F
If yes, return to and complete item 9 a-d.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
PATIENT AND INSURED INFORMATION
1
2
3
4
5
6
SIGNED DATE
14. DATE OF CURRENT:
MM DD YY
19. RESERVED FOR LOCAL USE
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.
ONSET 05/13/06
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DD YY
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
1. 3.
2. 4.
24. A. DATE(S) OF SERVICE
B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E.
From
To
PLACE OF
(Explain Unusual Circumstances)
DIAGNOSIS
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS
MODIFIER
POINTER
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
17b. NPI
5855 280 9
274 11
06 20 2012 06 20 2012
06 21 2012 06 21 2012
06 22 2012 06 22 2012
06 23 2012 06 23 2012
06 24 2012 06 24 2012
06 25 2012 06 25 2012
YES NO
a. b. a. b.
SIGNED
DATE
NUCC Instruction Manual available at: www.nucc.org
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)
SIGNED
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY
FROM
TO
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
FROM
TO
20. OUTSIDE LAB? $ CHARGES
YES NO
22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
5 J2501 KX 1,2 22.00 5
5 J2501 KX 1,2 22.00 5
5 J2916 KX 1,2 22.50 5
5 J2916 KX 1,3 73.10 10
5 J3370 KX 1,3 10.95 10
5 J3370 KX 1,3 10.95 10
55-5555555 x 12345678 x
Signature on File 07/10/2012
F. G. H. I. J.
DAYS EPSDT
OR Family
ID.
RENDERING
$ CHARGES UNITS Plan QUAL. PROVIDER ID. #
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$ $ $
32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
Renal Healthcare
3305 Bayshore Blvd.
Houston, TX 77777
NPI
3142650978
161.50
Renal Healthcare
3305 Bayshore Blvd.
Houston, TX 77777
NPI
3142650978
NPI
NPI
NPI
NPI
NPI
NPI
( )
1234567- 01
PHYSICIAN OR SUPPLIER INFORMATION
OP-54
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.