Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013<br />
OP.14<br />
Tuberculosis<br />
1500<br />
HEALTH INSURANCE CLAIM FORM<br />
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05<br />
PICA<br />
PICA<br />
CARRIER<br />
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP<br />
FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)<br />
CHAMPUS<br />
HEALTH PLAN BLK LUNG<br />
(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)<br />
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)<br />
3. PATIENT’S BIRTH DATE SEX<br />
MM DD YY<br />
Doe, Jane C. 12 06 1965 M<br />
F x<br />
5. PATIENT’S ADDRESS (No., Street)<br />
6. PATIENT RELATIONSHIP TO INSURED<br />
CITY<br />
Conroe<br />
ZIP CODE TELEPHONE (Include Area Code)<br />
77302<br />
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)<br />
a. OTHER INSURED’S POLICY OR GROUP NUMBER<br />
b. OTHER INSURED’S DATE OF BIRTH<br />
MM DD YY<br />
M<br />
c. EMPLOYER’S NAME OR SCHOOL NAME<br />
d. INSURANCE PLAN NAME OR PROGRAM NAME<br />
F<br />
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.<br />
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary<br />
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment<br />
below.<br />
SIGNED DATE<br />
14. DATE OF CURRENT:<br />
MM DD YY<br />
19. RESERVED FOR LOCAL USE<br />
x 123456789<br />
1200 Baltic Avenue<br />
( )<br />
ILLNESS (First symptom) OR<br />
INJURY (Accident) OR<br />
PREGNANCY(LMP)<br />
STATE<br />
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.<br />
GIVE FIRST DATE MM DD YY<br />
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)<br />
SEX<br />
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.<br />
V01 1<br />
Signature on File<br />
123 555-1234<br />
TX<br />
1. 3.<br />
17b. NPI<br />
x<br />
Self Spouse Child <strong>Other</strong><br />
8. PATIENT STATUS<br />
Single Married <strong>Other</strong><br />
Full-Time Part-Time<br />
Employed Student Student<br />
10. IS PATIENT’S CONDITION RELATED TO:<br />
a. EMPLOYMENT? (Current or Previous)<br />
b. AUTO ACCIDENT?<br />
c. OTHER ACCIDENT?<br />
YES NO<br />
YES NO<br />
YES NO<br />
10d. RESERVED FOR LOCAL USE<br />
x<br />
x<br />
x<br />
x<br />
PLACE (State)<br />
4. INSURED’S NAME (Last Name, First Name, Middle Initial)<br />
7. INSURED’S ADDRESS (No., Street)<br />
CITY<br />
STATE<br />
ZIP CODE TELEPHONE (Include Area Code)<br />
11. INSURED’S POLICY GROUP OR FECA NUMBER<br />
a. INSURED’S DATE OF BIRTH<br />
MM DD YY<br />
b. EMPLOYER’S NAME OR SCHOOL NAME<br />
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?<br />
YES NO<br />
SEX<br />
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize<br />
payment of medical benefits to the undersigned physician or supplier for<br />
services described below.<br />
SIGNED<br />
If yes, return to <strong>and</strong> complete item 9 a-d.<br />
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION<br />
MM DD YY MM DD YY<br />
FROM<br />
TO<br />
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES<br />
MM DD YY MM DD YY<br />
FROM<br />
TO<br />
20. OUTSIDE LAB? $ CHARGES<br />
YES NO<br />
22. MEDICAID RESUBMISSION<br />
CODE ORIGINAL REF. NO.<br />
23. PRIOR AUTHORIZATION NUMBER<br />
( )<br />
c. INSURANCE PLAN NAME OR PROGRAM NAME<br />
x<br />
M F<br />
PATIENT AND INSURED INFORMATION<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
2. 4.<br />
24. A. DATE(S) OF SERVICE<br />
B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E.<br />
From<br />
To<br />
PLACE OF<br />
(Explain Unusual Circumstances)<br />
DIAGNOSIS<br />
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS<br />
MODIFIER<br />
POINTER<br />
01 01 2012 01 01 2012<br />
01 01 2012 01 01 2012<br />
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?<br />
(For govt. claims, see back)<br />
31. SIGNATURE OF PHYSICIAN OR SUPPLIER<br />
INCLUDING DEGREES OR CREDENTIALS<br />
(I certify that the statements on the reverse<br />
apply to this bill <strong>and</strong> are made a part thereof.)<br />
Sally Green, ANP<br />
1 99204 TF AM 1 75.70 1<br />
1 71010 1 25.00 1<br />
YES NO<br />
F. G. H. I. J.<br />
DAYS EPSDT<br />
OR Family<br />
ID.<br />
RENDERING<br />
$ CHARGES UNITS Plan QUAL. PROVIDER ID. #<br />
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE<br />
$ $ $<br />
32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #<br />
NPI<br />
x<br />
Sally Green, ANP<br />
1242 Rosewood<br />
Conroe, TX 77307<br />
01 10 2012 a. b. a.<br />
SIGNED<br />
DATE<br />
9876543021<br />
b.<br />
1234567-01<br />
NUCC Instruction Manual available at: www.nucc.org<br />
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)<br />
100.70<br />
NPI<br />
NPI<br />
NPI<br />
NPI<br />
NPI<br />
NPI<br />
NPI<br />
( )<br />
PHYSICIAN OR SUPPLIER INFORMATION<br />
OP-58<br />
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.