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Please also check the
insurance billing manual updates and the
blog for more information.
Line by line instructions for filling out the HCFA 1500 form: Line 1. Other (usually) Line 1a. This is the ID number of the insured person, which is sometimes different from the client. It is usually the social security number, but that is now changing due to HIPAA requirements. It also could be a claim number in a MVA. Line 2. Patient’s name Line 3. Patient’s birth date: Male or Female Line 4. Insured’s name, Employer or whoever has the insurance policy , which may be different than the client: possibly a spouse or parent. Line 5. Patient’s address. Line 6. Patient’s relationship to insured. Line 7. Insured’s address : if same as patient put same. Line 8. Patient’s status Line 9 –9d Other insurance- if they have a secondary insurance that may kick in later. This could be a regular health insurance policy that may be billed for a MVA after funds are depleted or some other secondary insurance. Line 10. What is patient’s condition related to? Employment, auto accident or other. If you are billing a PPO for an Auto accident, be sure to check appropriate box. Line 11a. Insured’s Policy Number or Claim Number. Line 11b. Employer or School Line 11c. Insurance Plan name or program Line 12, 13. Have the client sign a release of records statement on their intake form and keep the form on file. Fill this in with “on file”. There may be states where you can’t do this. Line 14. Date of Injury or accident Line 15. If applicable Line 16. Provided by doctor Line 17. Name of referring physician Line 17a. ID number of referring physician (usually not needed) Line 18. Leave blank Line 19. Leave blank Line 20. Leave blank Line 21. Diagnosis Code. ICD-9 code. YOU MUST HAVE THIS! This number is provided by the physician. Even if they just put back pain, make the doctors give you the diagnosis code, even if you know what the code for back pain is. Line 23. Leave blank or put referral number from HMO or PPO. Line 24A. Dates of Service- one date per line. From and to are the same date. Line 24B. Place of Service. Ask the insurance codes they use. Every billing manual I have read says something different. It is usually a 3 , 11 or OF. Line 24C. Type of Service. Ask the insurance company what you should use. It is usually a 9 for ancillary services. Line 24D. CPT code goes here. Make sure you use the right CPT code for the procedure you are performing. Some companies will only pay for certain codes. See more on codes. Line 24E. Diagnosis Code – Indicate which code from line 21 you are treating for. Line 23F. Charges for Service- Total Charges Line 24G. Days or Units – codes are usually designating 15 minutes of treatment so one hour would be 4 units. Line 24 H-K. Leave Blank Line 25. Your federal ID Number or SS#. Line 26. Your patients account
number Line 28. Total Charges for all days Line 29. Enter amount of co-pay or other payment or leave blank Line 30. Balance Due Line 31. Your signature Line 32. Leave blank unless you provided service somewhere else besides your office which may or may not be legal. Line 33. Your name, address, provider number
Please also check the
insurance billing manual updates and the
blog for more information.
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