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When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.
The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Childrens Health Insurance Program, and the Health Insurance Marketplace.
How to fill out a CMS-1500 form The type of insurance and the insureds ID number. The patients full name. The patients date of birth. The insureds full name, if applicable. The patients address. The patients relationship to the insured, if applicable. The insureds address, if applicable. Field reserved for NUCC use.
Submission of the CMS 1500 (02/12) claim form should either be typed or computer printed forms. Handwritten forms can cause delays and errors in processing and slow down time for reimbursement. Ensure to use all capital typeface with Courier New or Tines New Roman font style and size 10.
Institutions use the UB-04 form to bill insurance for inpatient or outpatient medical and mental health claims. Examples include hospitals, hospices, rural health clinics, and comprehensive outpatient rehabilitation facilities.
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The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of
Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim.

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