How to Fill Out a HCFA 1500 Form

The HCFA 1500 form, now referred to as the CMS 1500, is used to file insurance claims and receive payments for medical services provided to patients. The HCFA 1500 form must be filled out properly to receive prompt payments and avoid insurance claim denials due to incomplete information. To fill out a HCFA 1500 form you will need specific patient information: patient's name, address, insured policy number and other pertinent information to obtain insurance payment approval.

Difficulty: Moderate

Instructions

Things You'll Need:

• Patient medical record Patient medical condition Patient signature Diagnosis code Authorization number Date of service Place of service Procedure code Federal tax identification number Charge amount Balance due Patient co-payment amount Physician signature Facility address Provider billing address

How to Fill Out a HCFA1500 Form

1. Use the information from the patient's medical records to fill out the HCFA 1500 form. Enter the following patient information: date of birth, gender, residential address, patient's relationship to the insured, group or policy number, insurance plan (HMO, PPO, or POS), employer, and marital status.

2. Check Yes or No to indicate if the patient's medical condition was a result of employment, auto accident or any other accidental involvement.

3. Have the patient sign the release of information and assignment of benefit portion of the HCFA 1500 form. The patient or an authorized person may sign this portion of the HCFA 1500 form.

4. Enter the appropriate diagnosis code. Diagnosis codes are listed in your ICD9 medical coding handbook.

5. Fill in the prior authorization number; this information is obtained prior to the patient receiving medical services by calling the 800 number on the insurance card.

6. Enter the date of service the patient was seen to receive medical services.

7. Enter the place where the medical services were performed.

8. Enter the correct procedure code; this is located on the check-out sheet.

9. Enter the physician's federal tax identification number in the box provided.

10. Fill in the box for the amount charged for the medical procedure.

11. Fill in the total amount due for the medical services; this amount will be paid based on the coordination of benefits policy.

12. Enter the patient's co-payment amount paid for the medical services. Some insurance companies have co-payments that the insured must pay; for example, the insured may be responsible for 20% of the billed amount and the insurance covers the remaining 80%.

13. Have the physician sign her name in the box allocated for the provider signature.

14. Enter the address of the facility the medical services were rendered.

15. Enter the provider's billing address if it is different from where the medical services were rendered. If the provider billing address is the same as the facility address simply enter "SAME". You have now completed the HCFA form 1500.

Tips & Warnings

• Read the insurance company billing guidelines carefully before filling out the HCFA 1500 form.

References

• HCFA 1500 Form for Medicaid
• Guide to Completing the HCFA 1500