Fillable Printable Sample Health Insurance Claim Form
Fillable Printable Sample Health Insurance Claim Form
Sample Health Insurance Claim 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
a. INSURED'S DATE OF BIRTH
b. EMPLOYER'S NAME OR SCHOOL NAME
c. INSURANCE PLAN NAME OR PROGRAM 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
F
HEALTH INSURANCE CLAIM FORM
OTHER
1. MEDICARE MEDICAID TRICARE CHAMPUS 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:
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
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
To
MM DD YY
1
2
3
4
5
6
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
32. SERVICE FACILITY LOCATION INFORMATION
SIGNED
MM DD YY
FROM TO
FROM TO
MM DD YY
MM DD YY
MM DD YY
MM DD YY
CODE
ORIGINAL REF. NO.
$ CHARGES
ID
QUAL..
RENDERING
PROVIDER ID. #
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$ $ $
33. BILLING PROVIDER INFO & PH # ( )
a.
b.
PICA
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
d. INSURANCE PLAN NAME OR PROGRAM NAME
NUCC Instruction Manual available at: www.nucc.org
YES NO
pp
( )
If yes, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
20. OUTSIDE LAB?
$ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CARRIER
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
p
M
p p
p p
F
YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICE
EMG
Place
of
Service
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
DIAGNOSIS
POINTER
1500
F
M
SEX
MM DD YY
YES NO
YES
NO
YES NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
p p
p p p p
p
Single Married Other
p p p
p p
p p
3. PATIENT'S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. PATIENT STATUS
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
p p
p
p
Employed Full-Time Part-Time
Student Student
Self Spouse Child Other
(Medicare #) (Medicaid #) (Sponsor's SSN) (Medicaid #) (SSN or ID) (SSN) (ID)
p
p
p
p
p p
p
M
SEX
p
DAYS
OR
UNITS
EPSDT
Family
Plan
F. G. H. I. J.
24.
A. B. C. D.
E.
p p
OMB No. 1240-0044
Expires: 01/31/2016
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
17a.
17 b.
NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
NPI
NPI
NPI
NPI
NPI
NPI
b.
a.
Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES'
COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS
COMPENSATION PROGRAM ACT of 2000 (EEOICPA)
GENERAL INFORMATION-FECA AND EEOICPA CLAIMANTS: Claims filed under FECA (5 USC 8101 et seq.) are for employment-related illness or
injury. Claims filed under EEOICPA (42 USC 7384 et seq.) are for compensable illnesses defined under that Act. All services, appliances, and supplies
prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to give relief, reduce the degree or period of the
disability or illness, or aid in lessening the amount of the monthly compensation, may be furnished. "Physician" includes all Doctors of Medicine (M.D.),
podiatrists, dentists, clinical psychologists, optometrists, chiropractors, or osteopathic practitioners within the scope of their practice as defined by State
law. However, the term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual
manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist.
FEES: The Department of Labor's Office of Workers' Compensation Programs (OWCP) is responsible for payment of all reasonable charges stemming
from covered medical services provided to claimants eligible under FECA and EEOICPA. OWCP uses a relative value scale fee schedule and other tests
to determine reasonableness. Schedule limitations are applied through an automated billing system that is based on the identification of procedures as
defined in the AMA's Current Procedural Terminology (CPT); correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate
payment. For specific information about schedule limits, call the Dept. of Labor's Federal Employees' Compensation office or Energy Employees
Occupational Illness Compensation office that services your area.
REPORTS: A medical report that indicates the dates of treatment, diagnosis(es), findings, and type of treatment offered is required for services provided
by a physician (as defined above). For FECA claimants, the initial medical report should explain the relationship of the injury or illness to the
employment. Test results and x-ray findings should accompany billings.
GENERAL INFORMATION-BLBA CLAIMANTS: The BLBA (30 USC 901 et seq.) provides medical services to eligible beneficiaries for diagnostic and
therapeutic services for black lung disease as defined under the BLBA. For specific information about reimbursable services, call the Department of
Labor's Black Lung office that services your facility or call the National Office in Washington, D.C.
SIGNATURE OF PHYSICIAN OR SUPPLIER: Your signature in Item 31 indicates your agreement to accept the charge determination of OWCP on
covered services as payment in full, and indicates your agreement not to seek reimbursement from the patient of any amounts not paid by OWCP for
covered services as the result of the application of its fee schedule or related tests for reasonableness (appeals are allowed). Your signature in Item 31
also indicates that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by
you or were furnished incident to your professional services by
your employee under your immediate personal supervision, except as otherwise expressly
permitted by FECA, Black Lung or EEOICPA 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 non-physicians must be included on the
bills. Finally, your signature indicates that you understand that any false claims, statements or documents, or concealment of a material act, may be
prosecuted under applicable Federal or State laws.
NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION
(PRIVACY ACT STATEMENT)
We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to
collect information is in 5 USC 8101 et seq.; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179. 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. Your response regarding the medical
service(s) received or the amount charged is required to receive payment for the claim. See 20 CFR ยงยง 10.801, 30.701, 725.406, 725.701, and 725.704.
Failure to supply the claim number or CPT codes will delay payment or may result in rejection of the claim because of incomplete information. 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 party payers to pay primary to Federal programs, 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. See Department of Labor
systems DOL/GOVT-1, DOL/ESA-5, DOL/ESA-6, DOL/ESA-29, DOL/ESA-30, DOL/ESA-43, DOL/ESA-44, DOL/ESA-49 and DOL/ESA-50 published in
the Federal Register, Vol. 67, page 16816, Mon. April 8, 2002, or as updated and republished.
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.
FORM SUBMISSION
FECA: Send all forms for FECA to the DFEC Central Mailroom, P.O. Box 8300, London, KY 40742-8300, unless otherwise instructed.
BLBA: Send all forms for BLBA to the Federal Black Lung Program, P.O. Box 8302, London, KY 40742-8302, unless otherwise instructed.
EEOICPA: Send all forms for EEOICPA to the Energy Employees Occupational Illness Compensation Program, P.O. Box 8304, London, KY
40742-8304, unless otherwise instructed.
INSTRUCTIONS FOR COMPLETING THE FORM: A brief description of each data element and its applicability to requirements under FECA, BLBA and
EEOICPA are listed below. For further information contact OWCP.
Item 1. Leave blank.
Item 1a. Enter the patient's claim number.
Item 2. Enter the patient's last name, first name, middle initial.
Item 3. Enter the patient's date of birth (MM/DD/YY) and check appropriate box for patient's sex.
Item 4. For FECA: leave blank. For BLBA and EEOICPA: complete only if patient is deceased and this medical cost was paid by a survivor or
estate. Enter the name of the party to whom medical payment is due.
Item 5. Enter the patient's address (street address, city, state, ZIP code; telephone number is optional).
Item 6. Leave blank.
Item 7. For FECA: leave blank. For BLBA and EEOICPA: complete if Item 4 was completed. Enter the address of the party to be paid.
Item 8. Leave blank.
Item 9. Leave blank.
Item 10. Leave blank.
Item 11. For FECA: enter patient's claim number. OMISSION WILL RESULT IN DELAYED BILL PROCESSING. For BLBA and EEOICPA:
leave blank.
OMB No. 1240-0044 OWCP-1500 PAGE 2 (Rev. 05-12)
Expires: 01/31/2016
Item 11a. Leave blank.
Item 11b. Leave blank.
Item 11c. Leave blank.
Item 11d. Leave blank.
Item 12. The signature of the patient or authorized representative authorizes release of the medical information necessary to process the claim, and
requests payment. Signature is required; mark (X) must be co-signed by witness and relationship to patient indicated.
Item 13. Signature indicates authorization for payment of benefits directly to the provider. Acceptance of this assignment is considered to be a
contractual arrangement. The "authorizing person" may be the beneficiary (patient) eligible under the program billed, a person with a
power of attorney, or a statement that the beneficiary's signature is on file with the billing provider.
Item 14. Leave blank.
Item 15. Leave blank.
Item 16. Leave blank.
Item 17. Leave blank.
Item 18. Leave blank.
Item 19. Leave blank.
Item 20. Leave blank.
Item 21. Enter the diagnosis(es) of the condition(s) being treated using current ICD codes. Enter codes in priority order (primary, secondary
condition). Coding structure must follow the International Classification of Disease, 9th Edition, Clinical Modification or the latest revision
published. A brief narrative may also be entered but not substituted for the ICD code.
Item 22. Leave blank.
Item 23. Leave blank.
Item 24. Column A: enter month, day and year (MM/DD/YY) for each service/consultation provided. If the "from" and "to" dates represent a series
of identical services, enter the number of services provided in Column G.
Column B: enter the correct CMS/OWCP standard "place of service" (POS) code (see below).
Column C: not required.
Column D: enter the proper five-digit CPT (current edition) code and modifier(s), the HCPCS, or the OWCP generic procedure code.
Column E: enter the diagnostic reference number (1, 2, 3 or 4 in Item 21) to relate the date of service and the procedure(s) performed to
the appropriate ICD code, or enter the appropriate ICD code.
Column F: enter the total charge(s) for each listed service(s).
Column G: enter the number of services/units provided for period listed in Column A. Anesthesiologists enter time in total minutes, not
units.
Column H: Leave blank.
Column I: Leave blank.
Column J: Enter NPI.
Item 25: Enter the Federal tax I.D.
Item 26: Provider may enter a patient account number that will appear on the remittance voucher.
Item 27: Leave blank.
Item 28: Enter the total charge for the listed services in Column F.
Item 29: If any payment has been made, enter that amount here.
Item 30: Enter the balance now due.
Item 31: For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable.
Item 32: Enter complete name of hospital, facility or physician's office were services were rendered. Item 32a. Enter NPI. Item 32b. Enter
taxonomy number.
Item 33: Enter (1) the name and address to which payment is to be made, and (2) your DOL provider number after "PIN #" if you are an individual
provider, or after "GRP #" if you are a group provider. FAILURE TO ENTER THIS NUMBER WILL DELAY PAYMENT OR CAUSE A
REJECTION OF THE BILL FOR INCOMPLETE/INACCURATE INFORMATION.
Item 33a. Enter NPI.
Item 33b. Enter taxonomy number.
Place of Service (POS) Codes for Item 24B
3 School
4 Homeless Shelter
5 Indian Health Service Free-Standing Facility
6 Indian Health Service Provider-Based Facility
7 Tribal 638 Free-Standing Facility
8 Tribal 638 Provider-Based Facility
11 Office
12 Patient Home
15 Mobile Unit
20 Urgent Care
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center (CMHC)
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service
OMB No. 1240-0044 OWCP-1500 PAGE 3 (Rev. 05-12)
Expires: 01/31/2016
Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 1240-0044. We estimate that it will take an average of seven minutes to complete this collection of information, including time for
reviewing instructions, abstracting information from the patient's records and entering the data onto the form. This time is based on
familiarity with standardized coding structures and prior use of this common form. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers'
Compensation Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office
of Management and Budget, Paperwork Reduction Project (1240-0044), Washington, DC 20503. DO NOT SEND THE COMPLETED
FORM TO EITHER OF THESE OFFICES.
NOTICE
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive
help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as sign language
interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your
claims examiner to ask about this assistance.
OMB No. 1240-0044 OWCP-1500 PAGE 4 (Rev. 05-12)
Expires: 01/31/2016
