Get Field Requirements For Cms-1500 Claim Form For Driscoll Health Plan Star And Chip Members Note 1
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Field Requirements For CMS-1500 Claim Form For Driscoll Health Plan STAR And CHIP Members Note 1 online
Filling out the CMS-1500 claim form accurately is crucial for successful submissions to Driscoll Health Plan for STAR and CHIP members. This guide provides clear and supportive directions on each section of the form to assist users in completing it online.
Follow the steps to complete the CMS-1500 claim form effectively.
- Press the ‘Get Form’ button to access the CMS-1500 claim form and open it in your editing interface.
- In Field 1, select ‘Medicaid’ for STAR claims or ‘Other’ for CHIP claims.
- Enter the recipient's ID number in Field 1a, exactly as it appears on their Medicaid/CHIP ID card.
- In Field 2, input the patient’s full name: last name, first name, and middle initial as shown on the ID card.
- Provide the patient's birth date (MM DD CCYY format) and indicate gender in Field 3.
- Complete Field 4 with the insured’s name in the format of last, first, and middle name.
- Fill in Field 5 with the patient’s address, including city, state, and zip code.
- If applicable, provide the patient’s relationship to the insured in Field 6.
- Complete Field 7 with the insured’s address and telephone number if available.
- If there is other insurance, provide the name in Field 9 and include the policy or group number in Field 9a.
- Fill out Fields 21 through 33 based on the provided instructions, entering diagnosis codes, services performed, and relevant identifiers as indicated.
- Once all necessary fields have been filled out, you can save changes, download, or print the completed form for submission.
Complete your CMS-1500 claim form online to ensure timely and accurate submissions.
To effectively fill out the CMS 1500 health insurance claim form for Driscoll Health Plan STAR and CHIP members, you will need essential information. First, gather the patient's personal details including their name and address. Next, obtain the health insurance policy number and the group number. Don't forget to include the provider's information, including their National Provider Identifier (NPI). Additionally, you will need the date of service and the diagnosis codes. Finally, ensure you have the total charges for the services provided.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.