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MHN/HMC Claims Department P. O. Box 14621 Lexington KY 40512-4621 HEALTH INSURANCE CLAIM FORM CHAMPUS Medicaid GROUP HEALTH PLAN SSN or ID CHAMPVA Sponsor s SSN VA File FECA BLK LUNG SSN 3. PATIENT S BIRTH DATE MM DD YY 2. PATIENT S NAME Last Name First Name Middle Initial CITY Spouse Child Single Married ZIP CODE 9. OTHER INSURED S NAME Last Name First Name Middle Initial Full-Time Part-Time Student 10. IS PATIENT S CONDITION RELATED TO a* EMPLOYMENT CURRENT OR PREVIOUS TELEPHONE INCLUDE AREA ...

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What is an HCFA 1500 form?

PURPOSE OF HEALTH INSURANCE CLAIM FORM - HCFA-1500. The Form HCFA-1500 answers the needs of many health insurers. It is the basic form prescribed by HCFA for the Medicare program for claims from physicians and suppliers, except for ambulance services.

What is a HCFA form used for?

The HCFA form is what non-institutional practitioners use to bill insurance companies for services provided. The HCFA form comprises medical billing codes and the patient's demographic and insurance information. To file an HCFA form, fill in all 33 boxes and run your form through a claim scrubber to identify errors.

What is a HCFA used for?

CMS-1500 Form (sometimes called HCFA 1500): This is the standard health insurance claim form used for submitting physician and professional claims to bill Medicare providers. In other words, the CMS-1500 is used for individual provider claims and is used to submit charges under Medicare Part-B.

Who fills out HCFA 1500 form?

The HCFA-1500 (CMS 1500) is a medical claim form employed by doctors, nurses, and professionals, including chiropractors and therapists to process the medical claim of a patient.

Who fills out HCFA 1500 form?

The HCFA-1500 (CMS 1500) is a medical claim form employed by doctors, nurses, and professionals, including chiropractors and therapists to process the medical claim of a patient.

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What is a HCFA statement?

An HCFA 1500 form is used to document a medical procedure. In essence, it is a claims form that the medical professional or the medical office completes and submits to the health insurance company.

What does HCFA stand for in medical billing?

Health Care Financing Administration, the agency that administers the Medicare, Medicaid, and Child Health Insurance programs. See full glossary.

Who fills out HCFA 1500 form?

The HCFA-1500 (CMS 1500) is a medical claim form employed by doctors, nurses, and professionals, including chiropractors and therapists to process the medical claim of a patient.

What is a HCFA claim?

The Health Care Finance Administration (HCFA) form is a claim form used in settlement of government insurance programs such as Medicare and Medicaid to medical providers. Developed by The Center of Medicaid and Medicare (CMS) but was adopted as a standard form by all Insurance plans.

Who is responsible for filling out a claim form?

Your employer should fill out the \u201cemployer\u201d section and forward the completed claim form to the insurance company. You should receive a copy of the completed claim form from your employer.

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