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  • 1500 0212 Form

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CMS 1500 Claim Form (version 02/12) that will accommodate reporting needs for ICD-10 and align with current requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3. Effective April 1, 2014, INTotal Health will begin accepting only the updated 1500 Claim Form version 02/12 for claims received on or after April 1, 2014. Please follow the guidelines outlined by the NUCC for completing the new claim form so that yo.

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The default setting for Box 22 on the HCFA 1500 form is "1-Original." There are times that a Payer will request that refiled claims show a specific re-submission code and sometimes a reference number that they provide you with. Common Re-Submission Codes Include: 6-Corrected. 7-Replacement.

The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form.

What is it? Box 22 is used to list the Original Reference Number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate frequency code: 6 - Corrected Claim. 7 - Replacement of Prior Claim.

Fill out the claim form, called the Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB).

Other CMS-1500 Codes Box 11b - Other Claim ID. ... Box 14 - Date of Current Illness, Injury, or Pregnancy (LMP) ... Box 15 - Other Date. ... Box 17 - Name of Referring Provider or Other Source. ... Box 17a, 19, 24i, 32b, 33b - Identifier Qualifiers. ... Box 21 - ICD indicator. ... Box 22 - Bill Frequency Code. ... Box 24h - EPSDT Reason Codes.

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.

Providers may use these instructions to complete this form. The CMS-1500 claim form has space for physicians and suppliers to provide information on other health insurance.

Professional Claims If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. • For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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