APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1.
M EDICARE ME
( Me Me dic dica a re re # )
( Me Me dic dica a id id # )
( Sp Sp on on so so r’s r’s SS SSN N)
GROUP HEALTH PLAN
(Member ID# )
( SSN SSN))
3. PATIENT’S BIRTH DATE MM DD YY
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
OTHER 1a. INSURED’S I.D. NUMBER
FECA BLK LUNG
( SSN SSN o r I D) D)
6. PATIENT RELATIONSHIP TO INSURED Self
IO T ZIP CODE
Full -T -Ti me me Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
TELEPHONE (Include Area Code)
7. INSURED’S ADDRESS (No., Street)
8. PATIENT STATUS
(For Program in Item 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
( ID ID )
Part-Ti me me Student
10. IS PATIENT’S CONDITION RELATED TO:
TELEPHONE TELEPHON Area TELEPH TELEPHON ONE (Include (Include clude Area Area Code) Code)
) R O F
LICY GROUP GROUP OR FECA ECA NUMBER 11. INSURED’S POLICY
a. EMPLOYMENT? (Current or Previous)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
YES b. OTHER INSURED’S DATE OF BIRTH MM DD YY
c. EMPLOYER’S NAME OR SCHOOL NAME
EMPLOYER’S NAME OR SCHOOL b.. EMPLOYER’S SCHOOL NAME NAME
T N EI
NO T A
d I S THERE THERE T ANOTHER T HE HE R HEALTH HEALTH H EA EA LT LT HBENEFIT BENEFIT B EN EN EF EF IT IT PLAN? d.. IS ANOTHER YES
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. er information n necessary 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other to process this claim. I also request payment of government benefits either to myself or to the party who hoaccepts acceptsassignment assignment assignme below.
If yes , return to and complete item 9 a-d.
13. 3. INSURED’S I NS U RIZED PERSON’S SIGNATURE I authorize 1 OR AUTHORIZED payment ay of medical benefits ts tto the undersigned physician or supplier for p services described below. ser
DATE ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)
10d. RESERVED FOR LOCAL USE
c. INSURANCE INSURANCE ANCE ANC E PLAN PLAN NAME NAM OR PROGRAM GRAM NAME NAME
14. DATE OF CURRENT: MM DD YY
c. OTHER ACCIDENT?
d. INSURANCE PLAN NAME OR PROGRAM NAME
b. AUTO ACCIDENT?
ED’S DATE OF BIRTH BIRTH a. INSURED’S a. INSURED’S M MM DD YY M
H AS H AD AD SAME SA OR SIMILAR SIMILAR R ILLNESS. ILL IL L NE NE SS SS . 16. DATES PATIENT AS HAD 15. IF PATIENT HAS HAS OR PATI UNABLE TO WORK IN CURRENT OCCUPATION DD YY Y MM DD YY MM DD YY ST DATE MM GIVE FIRST FROM FR FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION HOS HOSP DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO
17a. 17 7b 7b b.. N PI b. PI
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
late te Items Items 1, 2, 2, 33 or or44 to toItem 24Eby 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY INJURY (Relate to Item 24E 24E by Line) Line)
22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO.
$ CHARGES NO
23. PRIOR AUTHORIZATION NUMBER 2. 24. A. MM
DATE(S) OF SERVICE From To DD YY MM DD
4. 4. D. ES,, SERVICES, ES SER SERVI VICE CE , OR SUPPLIES SU D. PROCEDURES, PROCEDURES, SERVICES, (Explain Unusual ual Circumstances) Circumstance Circumsta PT/HCPCS MO CPT/HCPCS MODIFIER
E. DIAGNOSIS POINTER
F. $ CHARGES
DAYS OR UNITS
EPSDT ID. Family Plan QUAL.
PROVIDER ID. #
O F NI R
P P U S R O N IA
LT AX II. UM BE R .D 25.. FE 25 FEDE DERA RAL TAX TA I.D. D.. N NUMB NU MBER ER
SSN SS N EIN EIN
26.. PAT 26 PATIE IENT NT’S ’S AC ACCO COUN UNT T NO NO..
27. (ACCEPT ASSIGNMENT? ) For govt. claims, see back
YES H YS YS IC IC IA IA OR SUPPLIER 31. SIGNATURE OF PHYSICIAN ES O INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)
32. SERVICE FACILITY LOCATION INFORMATION
NUCC Instruction Manual available at: www.nucc.org
b. PLEASE PRINT OR TYPE
28. TOTAL CHARGE $
29. AMOUNT PAID $
33. BILLING PROVIDER INFO & PH #
30. BALANCE DUE
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 as upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPU S is not a health program but a insurance nsur nsu
orr should be p makes payment for health benefits provided certain affiliations with the Uniformed Services. Information on the patient’s sponsor provided in those items captioned in “Insured”; i.e., items 1a, through 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 requ req u rre e procedure proc pr p ro oce e and ns regarding regar ng required diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LACK K LUNG) LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were repersonally p ers erso o na na y furnished u rrn n s e byy me or o rwere w ere erefurnished u urn rrn ns e incident to my professional service by my employee under my immediate personal supervision, except as otherwisee expressly permitted permi rmitted rmi ttted ted by by M Medicare e or CHAMPU C CHAMPUS H AM P regulations.
For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under under the physician’s immediate ediate personal ssup upervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service,, 3) they ey must mus bee of o kinds n s commonly common y furnished u rrn n s e in n physician’s p offices, and 4) the services of nonphysicians must be included on the physician’s bills. e duty For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active u y mem m member em er o of the e Uniformed n or me Services erv er v ce ces s orr aa civilian c employee of the United States Government or a contract employee of the United States Government, eitherr civilian ilian ili an or or military militar mili tar (refer to 5 USC 5536). 53 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 ng law a w and a n regulations reg re g u a onns ns (42 CFR 424.32). . ).. NOTICE: Any one who misrepresents or falsifies essential information to receive payment ntt from Federal Federa funds requested quested by this this fo form rm ma may m 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 CT TS STATEMENT) STATEMENT) TAT ) We are authorized by CMS, CHAMPUS and OWCP to ask you for information on needed nee e in n the e administration a m n ss ra on of o the e Medicare, e car CHAMPUS, FECA, and Black Lung programs. Authority to collect information is in section 205(a), 1862, 1872 a and n 1874 o of the ee Social oc a Security ecur ecur ec ur y Act c as as amended, amen e 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 8101 et et seq; seq; and and 30 30 USC USC USC901 901 90 et et seq; seq; 38 38 USC USC 613; E.O. 9397.
The information we obtain to complete claims under these programs s isss used u se se to o identify enn y y o ou ou a and nn to o determine e e rm rm n e your y ou ou r eligibility. It is also used to decide if the services and supplies you received are covered by these programs and too insure nsure that a proper proper payment proper paym pa paymen ymen en iss made. ma e. m nsure The information may also be given to other providers of services, ess, s, carriers, caarre arrre r er errs s,, intermediaries, n eerrme rme a re s, s, medical me m e caa review revv e w boards, re o health plans , and other organizations or Federal agencies, for the effective administration of Federal provisions ns that req re requ quu re other o e err third r parties parr es payers pa paye pa p ay ay yers ers to ers o pay pa p ay primary to Federal program, and as otherwise necessary a require to administer these programs. For example, it may be necessary e ss ss ary ary to o disclose scc o se se information n or o rrma rm ma a o nabout a o u thee benefits en ne e s you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained e in n systems sys emss of o records. r ec ecor s. FOR MEDICARE CLAIMS: See the notice modifying arrier Claims Record,’ published in the Federal Register, Vol. 55 ng system sys em e m No. o. 09-70-0501, - , titled, e , ‘C a ar rr er er Medicare e No. 177, page 37549, Wed. Sept. 12, 1990, or as ass updated update upd ated d and an republished. blishe bli shed. d. FOR OWCP CLAIMS: Department of Labor,, Privacy of 1974,, ““Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28, r va vacy Act c o e p u ca o n o o ce o 1990, See ESA-5, ESA-6, ESA-12, ESA-13,, ESA-30, r aas s uupdated p a e an aand n re rrepublished. epu s e . - , oor FOR CHAMPUS CLAIMS: PRINCIPLE P PURPOSE(S): medical URPOSE(S): (S): To o eevaluate va ua ua e eeligibility g y for or m e c care provided by civilian sources and to issue payment upon establishment of eligibility and determination that thee services/supplies ser v ce ces supp es received reec ece vve are ar e authorized au or ze ze by law.
ROUTINE USE(S): Information from rom ro m claims c a ms aand n re related a e documents o cu ocumen ocu cumen me n s ma me may y be eg given v to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation consistent ns s en with w their er s statutory a u o ry ry a administrative m n s ra ve rresponsibilities e sp under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of the Secretary of Defense in civil ivil vil actions; to tothe Internal Internal Revenue e Service, Service, private priv p collection agencies, and consumer reporting agencies in connection with recoupment na claims; and to Congressional ona on a Offices ces ce s in n response respo res pons nse e too inquiries nqu nq u r es made ma a e at a the request of the person to whom a record pertains. Appropriate disclosures may be made ore o ruesse gen,, utilization governm gov g ovze ernmen en nevagences, aeegw e, quality prassurance, to other federal, state, agencies, individual providers of care, on matters relating entitlement, claims adjudication, fraud, program review, peerentities, review, and program integrity, third-party liability, coordination of to benefits, and civil and p ro r,olocal, goca gra ram m, abuse, aforeign sgn ugovernment aarnom nne rev rre w, quua ua yprivate ava as s su suer business criminal litigation related e a e to o the e operation opera on of o CHAMPUS..
DISCLOSURES: S: Voluntary; however, weve ver, r, failure fa to to provide prov pr ovid ide e inform info in information forr will result in delay in payment or may result in denial of claim. With the one exception discussed we below, there a are are re no penalties pena pe na es under un er these ese programs ese progr pro rograms grams amsfor or refusing re us to supply information. However, failure to furnish information regarding the medical services rendered or the amount ount charged c would prevent vent payment payment of of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay payment n o of the e claim. c aa m. Failure a ure too provide prov e medical me ca information n or under FECA could be deemed an obstruction. It is mandatory party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801ma man n ao ory or ry that ry a you you tell e us us if yo you u know now n ow ow that a another ano an o 3812 provide prov e penalties pena es for or withholding w o ng thiss information. n or or You Matching and Privacy Protection Act Ac t of 1988”, permits the government to verify information by way of computer matches. ou u should sh be aware ware that that P.L. P.L. 100-503, 100the he “Co ““Computer Co o MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I hereby re y agree aggre grree ee to o keep e ep ep such s uc uc rrecords rec re ecoor ec or s as a are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish erre information formation regarding reg any payments p a ym e claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.
I further r er agree agree to o accept, accep acce p , as as payment as pay paym m in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized or ze ze deductible, e uc e, coinsurance, co n co-payment or similar cost-sharing charge. SIGNATURE URE E OF PHYSICIAN PHYSICI (OR SUPPLIER): I certify that the services lis ted above were medically indicated and necessary to the health of this patient and were personally furnished urn s e byy me or my employee under my personal direction.
NOTICE: This iss to ce 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 n that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws. funds, and 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 collecti on is 0938-0999. The time required to complete this information collection is est imated 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.