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  • Cms 1500 Submission Sample - Wellcare

Get Cms 1500 Submission Sample - Wellcare

The only version of the CMS 1500 form that will be accepted by WellCare is the 02-12 version in this example. Submission Example Please refer to the NUCC (National Uniform Claim Committee Guide) for.

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How to fill out the CMS 1500 Submission Sample - WellCare online

Filling out the CMS 1500 Submission Sample - WellCare form is essential for efficiently processing your healthcare claims. This guide provides a clear, step-by-step approach to ensure accurate completion of this critical document.

Follow the steps to complete the CMS 1500 Submission Sample effectively.

  1. Press the ‘Get Form’ button to obtain the CMS 1500 Submission Sample and open it for editing.
  2. In Box 17, enter the name of the referring, ordering, or supervising provider. If you fill this box, include the appropriate qualifier in the left section, using 'DN' for referring, 'DK' for ordering, or 'DQ' for supervising.
  3. Input the provider's NPI in Box 17b. Optionally, provide the Taxonomy Code in Box 17a, preceded by the qualifier 'ZZ'.
  4. In the ICD Ind Box, indicate '9' for ICD-9 or '0' for ICD-10, noting that ICD-10 will not be accepted until mandated by CMS.
  5. For any drugs, list a valid NDC in the shaded area of Box 24, starting with the 'N4' qualifier. Ensure there are no spaces or dashes in the 11 digit code.
  6. Enter the rendering provider's Taxonomy Code in Box 24J, along with the 'ZZ' qualifier in Box 24I. Do not populate Box 24J if Boxes 31 and 33 are the same.
  7. If the Rendering Provider is identified in Box 31, provide the NPI in Box 24J.
  8. Fill out Box 25 with the required Federal Tax ID Number.
  9. In Box 32, enter the physical address where services were rendered. Note that this address cannot be a PO Box and is necessary if different from the Bill To Address.
  10. Provide the mailing address in Box 33, as well as the NPI in Box 33a. Add the Taxonomy code with the 'ZZ' qualifier in Box 33b.
  11. If the Rendering Provider's name differs from the Bill To Provider, type their name in the designated blank area above the 'SIGNED' and 'DATE' fields.
  12. Review all entries for accuracy and completeness. Save your changes, download, print, or share the form as needed.

Complete your forms online efficiently and ensure swift claims processing!

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Only uppercase characters should be used for procedure codes and modifiers. This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in Item 21 to relate the date of service and the items or services rendered to the primary diagnosis.

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.

The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers.

Submission of the CMS 1500 (02/12) claim form should either be typed or computer printed forms. Handwritten forms can cause delays and errors in processing and slow down time for reimbursement. Ensure to use all capital typeface with Courier New or Tines New Roman font style and size 10.

33b Required Billing Provider Info & Phone # (Pay-To) - Used for atypical providers only. Enter the Medi-Cal provider number for the billing provider.

1 a INSURED'S ID NUMBER Enter the patient's Medicaid identification number 2 PATIENT'S NAME Enter the recipient's name, exactly as it is spelled on the Medicaid ID card. Enter last name, first name and middle initial. Use commas to separate the last name, first name and middle initial.

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.

Medicare Part B paper claims may be filed using only the red printed (08/05) claim form. This form is appropriate for filing all types of health insurance claims to private insurers as well as government programs. Detailed instructions on completing the form are found below under the heading ' Instructions.

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Fill CMS 1500 Submission Sample - WellCare

Pdf icon CMS 1500 Submission Sample. Download. English. Claims Samples and Guidelines. The submission of the original red and white CMS 1500 claim form. Providers sending professional and supplier claims to Medicare on paper must use Form. CMS-1500 in a valid version. Claims Processing. Readmission.

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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
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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 WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
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