Tips for completing the cms1500 claim form beacon health. Sign, fax and printable from pc, ipad, tablet or mobile. Enter the patients medicaid id number in this item. Starting april 1, 2014 only the revised, 0212 version will be accepted. Medicare will begin accepting claims on the revised form, 0212, on january 6, 2014. The instructions for populating information onto the cms 1500 claim forms can be found on nuccs website at from the main page of the website, click on 1500 claim form and then select 0212 1500 claim form. A patients signature requests that payment be made and. Eaton vickers 823an00037k kbdg5v733c170n100extm2pe7h110 049a0102dwg06 02 5164 kdg4v3s2c15smuh560 849an00052a kbs1dg4v596l50m1f1pc7h810 082a0100dw from china suppliers on.
The nucc has developed this general instructions document. Cr 8509 contains the instructions for completing the revised cms 1500 claim form 0212, which will become part of chapter 26 in the medicare claims processing manual pub. Insureds name last name, first name, middle initial 7. Cms 1500 paper form billing guidelines frequently asked. Eaton vickers 823an00037k kbdg5v733c170n100extm2pe7h110 049a0102dwg06 025164 kdg4v3s2c15smuh560 849an00052a kbs1dg4v596l50m1f1pc7h810 082a0100dw from china suppliers on. Enter in the white, open carrier area the name and address of the payer to whom. The term, cms1500 claim form refers to the form generically, independent of a. Department of health and human services centers for. Cms1500 form instruction manual national uniform claim.
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