hcfa 1500 claim form
CMS 1500 BILLING INSTRUCTIONS
Provided on this page are some general billing reminders and specific instructions for billing on the CMS-1500 (12-90) claim form.
Providers should note the following:
- Providers may submit more than one claim per envelope to reduce provider postage costs and to aid Molina Medicaid Solutions in handling mail.
- Providers should always notify the Bureau of Health Services Financing (BHSF) when a mailing address change occurs to allow rejected claims to be returned more quickly to providers. Many claims are returned to Molina because forwarding orders at the post office have expired.
- Claims should be filed immediately after services have been provided.
- Medicaid is the payer of last resort.
Sample CMS 1500 claim form and instructions
NOTE: This form is available in Portable Document Format (PDF) and can be accessed using Adobe Acrobat Reader 3.0 or higher. If you do not already have Adobe Acrobat Reader 3.0 or higher, click Download Acrobat .
Professional services are billed on the CMS-1500 (formerly known as HCFA-1500) claim form. Items to be completed are either required or situational. Required information must be entered in order for the claim to process. Claims submitted with missing or invalid information in these fields will be returned unprocessed to the provider with a rejection letter listing the reason(s) the claims are being returned. These claims cannot be processed until corrected and resubmitted by the provider. Situational information may be required (but only in certain circumstances as detailed in the instructions below). Claims should be submitted to:
Molina Medicaid Solutions
P.O. Box 91020
Baton Rouge, LA 70821
*1.REQUIRED Enter an �X� in the box marked Medicaid (Medicaid )
*1A.REQUIRED Enter the recipient�s 13 digit Medicaid ID number exactly as it appears in the recipient�s current Medicaid information using the plastic Medicaid swipe card (MEVS), e-MEVS, or through REVS
NOTE : The recipients� 13-digit Medicaid ID number must be used to bill claims. The CCN number from the plastic ID card is NOT acceptable.
Note:If the 13-digit Medicaid ID number does not match the recipient�s name in block 2, the claim will be denied. If this item is blank, the claim will be returned.
*2.REQUIRED Print the name of the recipient: last name, first name, middle initial. Spell the name exactly as verified through MEVS, e-MEVS or REVS
3.SITUATIONAL Enter the recipient�s date of birth as reflected in the current Medicaid information available through MEVS, e-MEVS or REVS, using six (6) digits (MM DD YY). If there is only one digit in this field, precede that digit with a zero. Enter an �X� in the appropriate box to show the sex of the recipient.
4.SITUATIONAL Complete correctly if appropriate or leave blank
5.SITUATIONAL Print the recipient�s permanent address
6.SITUATIONAL Complete if appropriate or leave blank
7.SITUATIONAL Complete if appropriate or leave blank
9.SITUATIONAL Complete if appropriate or leave blank
9A.SITUATIONAL If recipient has no other coverage, leave blank. If there is other coverage, put the state assigned 6-digit TPL carrier code in this block – make sure the EOB is attached to the claim.
9B.SITUATIONAL Complete if appropriate or leave blank
9C.SITUATIONAL Complete if appropriate or leave blank
9D. SITUATIONAL Complete if appropriate or leave blank
11.SITUATIONAL Complete if appropriate or leave blank
11A.SITUATIONAL Complete if appropriate or leave blank
11B.SITUATIONAL Complete if appropriate or leave blank
11C.SITUATIONAL Complete if appropriate or leave blank
12.SITUATIONAL Complete if appropriate or leave blank
13.SITUATIONAL Obtain signature if appropriate or leave blank
14.SITUATIONAL Leave blank
17.SITUATIONAL If services are performed by a CRNA, enter the name of the directing physician.
If services are performed by an independent laboratory, enter the name of the referring physician.
If services are performed by a nurse practitioner or clinical nurse specialist, enter the name of the directing physician.
If the recipient is a lock-in recipient and has been referred to the billing provider for services, enter the lock-in physician�s name.
17A.SITUATIONAL If the recipient is linked to a PCP, the Primary Care Physician referral authorization number must be entered here.
18.SITUATIONAL Leave blank
*21.REQUIRED Enter the ICD-9 numeric diagnosis code and, if desired, narrative description. Use of ICD-9-CM coding is mandatory. Standard abbreviations of narrative descriptions are accepted.
22.SITUATIONAL Leave blank
23.SITUATIONAL Complete if required or leave blank
*24A.REQUIRED Enter the date of service for each procedure. Either six-digit (MMDDYY) or eight-digit (MMDDCCYY) format is acceptable.
*24B.REQUIRED Enter the appropriate code from the approved Medicaid place of service code list.
*24D.REQUIRED Enter the procedure code(s) for services rendered.
*24E.REQUIRED Reference the diagnosis entered in item 21 and indicate the most appropriate diagnosis for each procedure by entering either a �1�, �2�, etc. More than one diagnosis may be related to a procedure. Do not enter ICD-9-CM diagnosis code
*24F.REQUIRED Enter usual and customary charges for the service rendered
*24G.REQUIRED Enter the number of units billed for the procedure code entered on the same line in 24D
24H.SITUATIONAL Leave blank or enter a �Y� if services were performed as a result of an EPSDT referral
24K.SITUATIONAL Enter the attending provider number if group number is indicated in block 33
25.SITUATIONAL Leave blank
26.SITUATIONAL Enter the provider specific information assigned to identify the patient. This number will appear on the Remittance Advice (RA). It may consist of letters and/or numbers and may be a maximum of 16 characters.
27.SITUATIONAL Leave blank. Medicaid does not make payments to the recipient. Claim filing acknowledges acceptance of Medicaid assignment.
*28.REQUIRED Total of all charges listed on the claim
29.SITUATIONAL If block 9A is completed, indicate the amount paid; if no TPL, leave blank
30.SITUATIONAL If payment has been made by a third party insurer, enter the amount due after third party payment has been subtracted from the billed charges
*31.REQUIRED The claim form MUST be signed. The practitioner is not required to sign the claim form. However, the practitioner�s authorized representative must sign the form. Signature stamps or computer-generated signatures are acceptable, but must be initialed by the practitioner or authorized representative. If this item is left blank, or if the stamped or computer-generated signature does not have original initials, the claim will be returned unprocessed.
Date Enter the date of the signature
32.SITUATIONAL Complete as appropriate or leave blank
*33.REQUIRED Enter the provider name, address including zip code and seven (7) digit Medicaid provider identification number. The Medicaid billing provider number must be entered in the space next to �Group (Grp) .�
Note. If no Medicaid provider number is entered, the claim will be returned to the provider for correction and re-submission.
Marked (*) items must be completed or form will be returned.