Fillable Printable Insurance Claim Sample Form

Insurance Claim Sample Form

1a. INSURED’S I.D. NUMBER

(For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY

STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

INSURED’S DATE OF BIRTH

EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize

payment of medical benefits to the undersigned physician or supplier for

services described below.

SEX

HEALTH INSURANCE CLAIM FORM

OTHER

1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment

below.

SIGNED DATE

ILLNESS (First symptom) OR

INJURY (Accident) OR

PREGNANCY(LMP)

MM DD YY

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE

MM DD YY

14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

From

MM DD YY

25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?

(

For govt. claims, see back

)

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

INCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverse

apply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

MM DD YY

CODE

ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY

STATE

ZIP CODE TELEPHONE

(Include Area Code)

9. OTHER INSURED’S NAME

(Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes

, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CARRIER

PATIENT AND INSURED INFORMATION

PHYSICIAN OR SUPPLIER INFORMATION

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICE

PLACE OF

SERVICE

PROCEDURES, SERVICES, OR SUPPLIES

(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSIS

POINTER

SEX

MM DD YY

YES

PLACE (State)

GROUP

HEALTH PLAN

FECA

BLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

EMPLOYMENT? (Current or Previous)

b. AUTO

ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed

Student Student

Self Spouse

Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

SEX

DAYS

UNITS

F. H. I. J.24. A. B.

C. D.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

EMG

RENDERING

32. SERVICE FACILITY LOCATION INFORMATION

33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

EPSDT

Family

Plan

ID.

QUAL.

NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY

APPLICABLE PROGRAMS.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may

be guilty of a criminal act punishable under law and may be subject to civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLY

MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process

the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature

authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health

insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42

CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or

CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,

and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge

determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but

makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in those

items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.

BLACK LUNG AND FECA CLAIMS

The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and

diagnosis coding systems.

SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)

I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished

incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS

regulations.

For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision

by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s

offices, and 4) the services of nonphysicians must be included on the physician’s bills.

For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employee

of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims,

I further certify that the services performed were for a Black Lung-related disorder.

No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32).

NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject

to fine and imprisonment under applicable Federal laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION

(PRIVACY ACT STATEMENT)

We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lung

programs. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and

44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services

and supplies you received are covered by these programs and to insure that proper payment is made.

The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federal

agencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary

to administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures

are made through routine uses for information contained in systems of records.

FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55

No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished.

FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28,

1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished.

FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment

of eligibility and determination that the services/supplies received are authorized by law.

ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or

the Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of

the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment

claims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made

to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claims

adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and

criminal litigation related to the operation of CHAMPUS.

DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussed

below, there are no penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services rendered

or the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay

payment of the claim. Failure to provide medical information under FECA could be deemed an obstruction.

It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801-

3812 provide penalties for withholding this information.

You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.

MEDICAID PAYMENTS (PROVIDER CERTIFICATION)

I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish

information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.

I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception

of authorized deductible, coinsurance, co-payment or similar cost-sharing charge.

SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were

personally furnished by me or my employee under my personal direction.

NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State

funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB

control number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including the

time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the

accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

21244-1850.

This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.

__ __ __

1 2

4 TYPE

OF BILL

FROM THROUGH

5 FED.TAX NO.

ECI

A B C D E F G

I J K L

N O P Q

ADMISSION

CONDITION CODES

DATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPAN

CODEDATE CODE CODE CODE DATE

CODE THROUGH

VALUE CODES VALUE CODES VALUE CODES

CODE AMOUNT

CODEAMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b.OTHER PROCEDURE

NPI

CODE DATE CODE DATE CODE DATE

FIRST

c. d. e.OTHER PROCEDURE

NPI

CODE DATE DATE

FIRST

NPI

LAST

FIRST

NPI

LAST

FIRST

UB-04 CMS-1450

10 BIRTHDATE 11 SEX

12 13 HR 14 TYPE

15 SRC

DATE

DHR

181920

FROM

21 2522 26 2823 27

CODE FROM

DATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

INFO

BEN.

CODE

OTHER PROCEDURE

THROUGH

ACDT

3231 33 34 35 36 37

38 39 40 41

42 REV.CD. 43 DESCRIPTION 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52REL

51 HEALTH PLAN ID

53ASG.

54 PRIOR PAYMENTS

55 EST.AMOUNT DUE

56 NPI

INSURED’S

NAME 59

P.REL 60

INSURED’S

UNIQUE

GROUP

NAME

INSURANCE

GROUP

NO.

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

69 ADMIT 70 PATIENT

ATTENDING

REMARKS

OTHER PROCEDURE

OPERATING

OTHER

81CC

CREATION DATE

PAT.

CNTL

b.MED.

REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

STATEMENT

COVERS

PERIOD

9 PATIENT ADDRESS

STAT

STATE

REASON DX

71 PPS

CODE

QUAL

LAST

National Uniform

Billing Committee

NUBC

™

OCCURRENCE

QUAL

CODE DATE

Submission of this claim constitutes certification that the billing

information as shown on the face hereof is true, accurate and complete.

That the submitter did not knowingly or recklessly disregard or

misrepresent or conceal material facts. The following certifications or

verifications apply where pertinent to this Bill:

1. If third party benefits are indicated, the appropriate assignments by

the insured /beneficiary and signature of the patient or parent or a

legal guardian covering authorization to release information are on file.

Determinations as to the release of medical and financial information

should be guided by the patient or the patient’s legal representative.

2. If patient occupied a private room or required private nursing for

medical necessity, any required certifications are on file.

3. Physician’s certifications and re-certifications, if required by contract

or Federal regulations, are on file.

4. For Religious Non-Medical facilities, verifications and if necessary re-

certifications of the patient’s need for services are on file.

5. Signature of patient or his representative on certifications,

authorization to release information, and payment request, as

required by Federal Law and Regulations (42 USC 1935f, 42 CFR

424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other

applicable contract regulations, is on file.

6. The provider of care submitter acknowledges that the bill is in

conformance with the Civil Rights Act of 1964 as amended. Records

adequately describing services will be maintained and necessary

information will be furnished to such governmental agencies as

required by applicable law.

7. For Medicare Purposes: If the patient has indicated that other health

insurance or a state medical assistance agency will pay part of

his/her medical expenses and he/she wants information about

his/her claim released to them upon request, necessary authorization

is on file. The patient’s signature on the provider’s request to bill

Medicare medical and non-medical information, including

employment status, and whether the person has employer group

health insurance which is responsible to pay for the services for

which this Medicare claim is made.

8. For Medicaid purposes: The submitter understands that because

payment and satisfaction of this claim will be from Federal and State

funds, any false statements, documents, or concealment of a

material fact are subject to prosecution under applicable Federal or

State Laws.

9. For TRICARE Purposes:

(a) The information on the face of this claim is true, accurate and

complete to the best of the submitter’s knowledge and belief, and

services were medically necessary and appropriate for the health

of the patient;

(b) The patient has represented that by a reported residential address

outside a military medical treatment facility catchment area he or

she does not live within the catchment area of a U.S. military

medical treatment facility, or if the patient resides within a

catchment area of such a facility, a copy of Non-Availability

Statement (DD Form 1251) is on file, or the physician has certified

to a medical emergency in any instance where a copy of a Non-

Availability Statement is not on file;

directly to the provider’s request to identify all health insurance

coverage, and that all such coverage is identified on the face of

the claim except that coverage which is exclusively supplemental

payments to TRICARE-determined benefits;

(d) The amount billed to TRICARE has been billed after all such

coverage have been billed and paid excluding Medicaid, and the

amount billed to TRICARE is that remaining claimed against

TRICARE benefits;

(e) The beneficiary’s cost share has not been waived by consent or

failure to exercise generally accepted billing and collection efforts;

and,

(f) Any hospital-based physician under contract, the cost of whose

services are allocated in the charges included in this bill, is not an

employee or member of the Uniformed Services. For purposes of

this certification, an employee of the Uniformed Services is an

employee, appointed in civil service (refer to 5 USC 2105),

including part-time or intermittent employees, but excluding

contract surgeons or other personal service contracts. Similarly,

member of the Uniformed Services does not apply to reserve

members of the Uniformed Services not on active duty.

(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers

participating in Medicare must also participate in TRICARE for

inpatient hospital services provided pursuant to admissions to

hospitals occurring on or after January 1, 1987; and

(h) If TRICARE benefits are to be paid in a participating status, the

submitter of this claim agrees to submit this claim to the

appropriate TRICARE claims processor. The provider of care

submitter also agrees to accept the TRICARE determined

reasonable charge as the total charge for the medical services or

supplies listed on the claim form. The provider of care will accept

the TRICARE-determined reasonable charge even if it is less

than the billed amount, and also agrees to accept the amount

paid by TRICARE combined with the cost-share amount and

deductible amount, if any, paid by or on behalf of the patient as

full payment for the listed medical services or supplies. The

provider of care submitter will not attempt to collect from the

patient (or his or her parent or guardian) amounts over the

TRICARE determined reasonable charge. TRICARE will make

any benefits payable directly to the provider of care, if the

provider of care is a participating provider.

UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION

OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR

CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE

FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

SEE http://www.nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS