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  • 2017 Claim Form Filled Out

Get 2017 Claim Form Filled Out

Nature of Physician or Supplier Date: 38. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office) 39. Physician s, Supplier s Billing Name, Address, Zip Code & Phone No. Signed: 38a. NPI 38b. Other ID Form Revised: September 2014 2017 Claim Form Instructions Block No. Description Guidelines Required (Paper) 1 Program Check the box for the specific program to which these services are billed: XIX, DFPP, PHC, EPHC (All) Family Planning Progra.

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Other CMS-1500 Codes Y4. Property Casualty Claim Number. 431. Onset of Current Symptoms or Illness. 484. ... 454. Initial Treatment. 304. ... DN. Referring Provider. DK. ... 0B. State License Number. 1G. ... ICD-9-CM. ICD-10-CM. Replacement of prior claim. Void/cancel of prior claim. AV. Available – Not Used (Patient refused referral.) S2.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

Enter the patient's last name, first name, and middle initial, if any, as it appears on the patient's Medicare card (e.g., Jones John J). Include only one space between the last name, first name, and middle initial. If the name is not an identical match, the claim will be rejected as unprocessable.

Fill your claim form and attach the relevant documents Make sure you fill it with utmost accuracy. You need to attach certain documents along with the claim form. For example, when making a health insurance claim, you need share documents like hospital bills, discharge summary, and doctor's prescriptions.

When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.

Understanding the CMS-1500 Form There are 33 boxes in a CMS-1500 form. All of these boxes must be filled for the insurance claim to pass through.

Block 33. • Enter the address of the provider who is billing for the service. • Enter the 9-digit individual or group OWCP Provider ID of the provider who is. billing for the service. •

Box 17a. The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232