- Health Insurance Claim Form Approved By National Uniform Claim Committee Nucc 02 12 1 2 3 4 5 6 Pica 1 Medicare Medic 1 (197.51 KiB) Viewed 51 times
- Health Insurance Claim Form Approved By National Uniform Claim Committee Nucc 02 12 1 2 3 4 5 6 Pica 1 Medicare Medic 2 (154.24 KiB) Viewed 51 times
HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 1 2 3 4 5 6 PICA 1. MEDICARE MEDICAID (Medicare) (Medicaid) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 5. PATIENT'S ADDRESS (No., Street) CITY ZIP CODE b. RESERVED FOR NUCC USE a. OTHER INSURED'S POLICY OR GROUP NUMBER c. RESERVED FOR NUCC USE 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) TRICARE (ID#/DoD#) d. INSURANCE PLAN NAME OR PROGRAM NAME TELEPHONE (Include Area Code) QUAL 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE SIGNED 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) MM DDI YY 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) I. 24. A. MM DATE(S) OF SERVICE From To DD YY MM DD 25. FEDERAL TAX I.D. NUMBER CHAMPVA (Member ID#) B. C. PLACE OF YY SERVICE EMG STATE SSN EIN 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.) DATE 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. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) A. L B. L c. L G. L E. L F. L J. L K. a. 3. PATIENT'S BIRTH DATE MM DD GROUP HEALTH PLAN (ID#) SIGNED NUCC Instruction Manual available at: www.nucc.org 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other 8. RESERVED FOR NUCC USE a. EMPLOYMENT? (Current or Previous) YES NO b. AUTO ACCIDENT? 10.IS PATIENT'S CONDITION RELATED TO: 17a. ---+ 17b. NPI FECA BLK LUNG (ID#) 15. OTHER DATE QUAL. YES c. OTHER ACCIDENT? YES NO 10d, CLAIM CODES (Designated by NUCC) DATE 26. PATIENT'S ACCOUNT NO. NPI SEX MM DD D. L H. L L. L D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER ICD Ind. 32, SERVICE FACILITY LOCATION INFORMATION NO F OTHER 1a. INSURED'S I.D. NUMBER (ID#) YY DIAGNOSIS POINTER 27. ACCEPT ASSIGNMENT? For govt. claims seo back) YES NO PLEASE PRINT OR TYPE PLACE (State) b. OTHER CLAIM ID (Designated by NUCC) U 4, INSURED'S NAME (Last Name, First Name, Middle Initial) 7. INSURED'S ADDRESS (No., Street) CITY ZIP CODE a. INSURED'S DATE OF BIRTH MM DD YY 11. INSURED'S POLICY GROUP OR FECA NUMBER c. INSURANCE PLAN NAME OR PROGRAM NAME FROM 20. OUTSIDE LAB? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, complete items 9, 9a, and 9d. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. YES 22. RESUBMISSION TELEPHONE (Include Area Code) SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD FROM 1 1 TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM TO $ CHARGES CODE 8. NO F. $ CHARGES 23. PRIOR AUTHORIZATION NUMBER PICA (For Program in Item 1) ORIGINAL REF. NO. G. H. DAYS EPSAT EPSOT OR Family UNITS Plan QUAL 10. -- NPI NPI NPI NPI STATE SEX NPI NPI 28, TOTAL CHARGE 29, AMOUNT PAID $ $ 33. BILLING PROVIDER INFO & PH # RENDERING PROVIDER ID, # 30, Rsvd for NUCC Use — CARRIER PATIENT AND INSURED INFORMATION NPI APPROVED OMB-0938-1197 FORM 1500 (02-12) PHYSICIAN OR SUPPLIER INFORMATION 1
Using the following information listed below input the information using the CMS 1500 and the authorization form. Billing Provider info: College Clinic 4567 Broad Avenue Phone no: 555-486-9002 NPI: 3664021CC TIN: XX12210XX Woodland, XY 12345-0001 Service Facility Location Information: College Hospital 4500 Broad Avenue Woodland Hills, XY 12345-0001 NPI: 950730067 PATIENT: Drake, Stephen DOB: 04-03-1991 SEX: M Home phone: 555-277-5831 Patient SSN: 586-XX-0061 Patient Occupation: FT Student Date 5/1/XX MB160 Patient Record Record Number 13-4 Patient Information Name of insurance: Medicaid Insured or Subscriber: Self Medicaid no: 19-37-1524033-16X 5/8/xx 2317 Charnwood Avenue Woodland Hills, XY 12345-0001 Referred by: James B. Jeffers, MD, 100 S. Broadway, Woodland Hills, XY 12345 Provider NPI: 12345069XX Progress Notes NP comes in complaining of severe sore throat since April 4. A detailed hx was taken. Mother states Stephen has had many bouts of adenoid symptoms and tonsilitis since age 4. He has missed school on three occasions this year due to throat infections. Did complete phys exam (D) which showed enlargement & inflammation of tonsils and adenoids. Temp 101.2. Strep culture done (screening) with a preliminary report; positive for strep. Administered penicillin G (Bacillin) 1.2 million units IM and wrote Rx to start AB and continue x 10 d. Imp: Acute tonsilitis (LC MDM) RTO 1 week. Gerald Practon, MD Pt returns; sore throat improved but still swollen. Tonsils are 4+ hypertrophic. Received medical records from past primary physician which indicated hx of 5 bouts of strep over last 3 yrs. Adv tonsillectomy and adenoidectomy. Submitted prior authorization for hospitalization. Pt to be admitted tomorrow for one day surgery (PF HX/PX SF MDM). Gerald Practon, MD