CMS 4 page Brochure

Health Insurance Claim Forms:
Your Prescription for Compliant, Convenient Billing
Revised CMS-1500 Released
The National Uniform Claim Committee (NUCC) has released a revised CMS-1500 Health Insurance
Claim Form (version 02/12) to replace the current form (version 08/05). The new form will go into
effect on January 6, 2014. From January 6 until March 31, providers can use either the current form
or the revised form. On April 1, the current form is discontinued. Only the new version will be accepted.
Satisfy recordkeeping requirements with
CMS-1500 Health Insurance Claim Forms
… for use by all medical facilities
Per federal regulations, all healthcare providers
must use the CMS-1500 Form for specific types
of billing. The CMS-1500 accommodates
reporting of the National Provider Identifier,
which must be used by all HIPAA-covered entities.
• Printed with OCR “dropout” red ink on 20# paper,
as per government regulations
• Available in continuous, laser and snap-apart
02/12 Version CMS-1500 Laser-Cut and Continuous Forms
Item #
Item Description
Paper/Sequence
Quantity
Per Case
CMS12LC
Laser-Cut Sheet (02/12)
20# (W)
2,500
CMS12LC1
Laser-Cut Sheet (02/12)
20# (W)
1,000
CMS12LC250
Laser-Cut Sheet (02/12)
20# (W)
250
CMS12LC500
Laser-Cut Sheet (02/12)
20# (W)
500
CMS121
1-Part Continuous (02/12)
20# (W)
2,500
CMS1211
1-Part Continuous (02/12)
20# (W)
1,000
CMS122
2-Part Continuous (02/12)
Carbonless (W/C)
1,000
CMS12W2
2-Part Continuous (02/12)
Carbonless (W/W)
1,000
CMS123
3-Part Continuous (02/12)
Carbonless (W/C/P)
1,000
Paper/Sequence (W) White (C) Canary (P) Pink
CMS-1500 Blown-On Self-Imaging Labels – Continuous
Item #
Item Description
Paper/Sequence
Quantity
Per Case
CMS121B
1-Part w/Label (02/12)
20# (W)
1,000
CMS122B
2-Part w/Label (02/12)
Carbonless (W/C)
1,000
Paper/Sequence (W) White (C) Canary (P) Pink
CMS-1500 2-Part Snap-Apart Form
Item #
CMS12S
Item Description
2-Part (02/12)
Paper/Sequence (W) White (C) Canary
Paper/Sequence
Carbonless (W/C)
Quantity
Per Case
500
Compliance is Critical
What makes a CMS-1500 or UB-04 form compliant?
A number of factors. For starters, these forms must adhere to strict printing standards that
govern the layout, paper and ink. Each must have accurate content and must conform to the
Health Insurance Portability and Accountability Act (HIPAA).
These billing forms were developed in conjunction with all the governing agencies, including
the National Uniform Claim Committee, the National Uniform Billing Committee, the CMS Centers
for Medicare and Medicaid Services, the Health and Human Services Agency and the American
Hospital Association.
So you can be confident our forms are the most up-to-date and in full compliance with the law.
Reduce billing errors with
UB-04 Health Insurance Claim Forms
… for use by hospitals and institutions
Designed for hospitals to file a medical claim with
the patient’s insurance carrier, Form UB-04 is printed
with OCR “dropout” red ink on 20# paper.
• Available in both continuous and laser formats
• All parts printed on white carbonless stock
UB-04 Health Insurance Claim Forms (CMS-1450)
Item #
Item Description
Paper/Sequence
Quantity
Per Case
UB04LC
UB-04 Laser-Cut Sheet
20# (W)
2,500
UB041
UB-04 1-Part Continuous
20# (W)
2,500
UB042
UB-04 2-Part Continuous
Carbonless (WW)
1,000
UB043
UB-04 3-Part Continuous
Carbonless (W/W/W)
1,000
UB044
UB-04 4-Part Continuous
Carbonless (W)
500
UB045
UB-04 5-Part Continuous
Carbonless (W)
500
Paper/Sequence (W) White
Statement of Actual Services
Request for Predetermination/Preauthorization
EPSDT / Title XIX
POlICyHOlDER/SUBSCRIBER INFORmATION (For Insurance Company Named in #3)
2. Predetermination/Preauthorization Number
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
INSURANCE COmPANy/DENTAl BENEFIT PlAN INFORmATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Policyholder/Subscriber ID (SSN or ID#)
F
M
OTHER COVERAgE (Mark applicable box and complete items 5 -11. If none, leave blank.)
Medical?
4. Dental?
16. Plan/Group Number
PATIENT INFORmATION
fold
7. Gender
M
F
9. Plan/Group Number
Spouse
12. Policyholder/Subscriber
Name (Last,
First, Middle Initial,
Address,
City, State,
10. Patient’s
Relationship
to Suffix),
Person
named
in #5Zip Code
INSURANCE COmPANy/DENTAl BENEFIT PlAN INFORmATION
Self
3. Company/Plan Name, Address, City, State, Zip Code
Spouse
Dependent
M
OTHER COVERAgE (Mark applicable box and complete items 5 -11. If none, leave blank.)
Medical?
4. Dental?
15. Policyholder/Subscriber ID (SSN or ID#)
14. Gender
16. Plan/Group Number
21. Date of Birth (MM/DD/CCYY)
F
17. Employer Name
fold
M
8. Policyholder/Subscriber ID (SSN or ID#)
F
Self
Spouse
Dependent
19. Reserved For Future
Use28. Tooth
18. Relationship
to Policyholder/Subscriber
in #12 Above
25. Area
26.
Self
of Oral
27. Tooth Number(s)
Other
or Letter(s)
Spouse
Tooth
Dependent Child
Surface
System
20. NameCavity
(Last, First,
Middle Initial, Suffix), Address, City, State, Zip Code
29. Procedure
Code
fold
24. Procedure Date
(MM/DD/CCYY)
7. Gender
10. Patient’s Relationship to Person
1 named in #5
F
M
PATIENT
INFORmATION
RECORD OF SERVICES
PROVIDED
6. Date of Birth (MM/DD/CCYY)
23. Patient ID/Account # (Assigned by Dentist)
22. Gender
• Available in both continuous and laser formats
• 100% compliant to meet ADA guidelines
(If both, complete 5-11 for dental only.)
5. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Suffix)
9. Plan/Group Number
Other
This is the latest version of the claim/attending dentist form.
It’s authorized by the American Dental Association (ADA).
Other
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
Dependent Child
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
POlICyHOlDER/SUBSCRIBER INFORmATION (For Insurance Company Named in #3)
2. Predetermination/Preauthorization Number
Self
8. Policyholder/Subscriber ID (SSN or ID#)
29a. Diag.
Pointer
29b.
Qty.
30. Description
31. Fee
Other
2
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
ADA Dental Claim Forms
3
21. Date of Birth (MM/DD/CCYY)
4
25. Area 26.
of Oral Tooth
Cavity System
M
27. Tooth Number(s)
or Letter(s)
28. Tooth
Surface
6
29. Procedure
Code
29a. Diag.
Pointer
29b.
Qty.
F
30. Description
Item #
31. Fee
7
1
2
8
3
5
10
6
8
1
2
3
4
5
6
7
8
32
31
30
29
28
27
26
25
9
10
fold
1
2
3
4
5
6
7
8
9
10
11
12
13
32
31
30
29
28
27
26
25
24
23
22
21
20
35. Remarks
10
11
12
13
14
23
22
21
20
19
14
15
16
34a. Diagnosis Code(s)
A _________________
C _________________
19
18
17
(Primary diagnosis in “A”)
B _________________
D _________________
(Primary diagnosis in “A”)
n
45. Treatment Resulting from
37. I hereby authorize and direct
payment of the dental benefits
otherwise payable
to me, directly
Occupational illness/injury
Auto accident
Other accident
X _____________________________________________________________________________
to the below named dentist or dental entity.
Subscriber Signature
Date
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
BIllINg DENTIST OR DENTAl ENTITy (Leave blank if dentist or dental entity is not
TREATINg DENTIST AND TREATmENT lOCATION INFORmATION
_____________________________________________________________________________
submitting claim on behalf of the patient or insured/subscriber.)
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
Subscriber Signature multiple visits) or have been completed.
Date
X
48. Name, Address, City, State, Zip Code
BIllINg DENTIST X
OR
DENTAl ENTITy (Leave blank if dentist or dental entity is not
________________________________________________________________________________
Signed
Date
submitting claim on behalf of
the (Treating
patientDentist)
or insured/subscriber.)
54. NPI
55. License Number
56.State,
Address, Zip
City, State,
48. Name, Address, City,
CodeZip Code
49. NPI
50. License Number
52. Phone
Number (
)
-
©2012 American Dental Association
56a. Provider
Specialty Code
51. SSN or TIN
52a. Additional
Provider ID
57. Phone
Number
(
New!
1-Part Continuous (2012)
Carbonless (W/W)
2,500
New!
12011
1-Part Continuous (2012)
20# (W)
1,000
New!
1202
40. Is Treatment for Orthodontics?
2-Part Continuous (2012)
Carbonless (W/C)
1,000
20# (W)
2,500
20# (W)
2,500
Carbonless (W/C)
1,000
)
58. Additional
Provider ID
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)
1201
D _________________
ANCIllARy ClAIm/TREATmENT INFORmATION
38. Place of Treatment
n
No (Skip 41-42)
42. Months of Treatment
Remaining
41. Date Appliance Placed (MM/DD/CCYY)
Yes (Complete 41-42)
2600
Laser-Cut Sheet (2006)
43. Replacement of Prosthesis
No
2601
45. Treatment Resulting from
Occupational illness/injury
52. Phone
Number (
1-Part Continuous (2006)
-
©2012 American Dental Association
Other accident
Auto accident
2602
2-Part Continuous (2006)
TREATINg DENTIST AND TREATmENT lOCATION INFORmATION
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
Paper/Sequence (W) White (C) Canary
Additional previous versions 2004, 2000 and older with compatible
envelopes available only until current inventory is depleted.
X________________________________________________________________________________
Signed (Treating Dentist)
-
50. License Number
)
44. Date of Prior Placement (MM/DD/CCYY)
Yes (Complete 44)
54. NPI
Date
55. License Number
56a. Provider
Specialty Code
56. Address, City, State, Zip Code
49. NPI
39. Enclosures (Y or N)
(e.g. 11=office; 22=O/P Hospital)
(Use “Place of Service Codes for Professional Claims”)
Yes (Complete 41-42)
X _____________________________________________________________________________
X _____________________________________________________________________________
44. Date of Prior Placement (MM/DD/CCYY)
42. Months of Treatment
43. Replacement of Prosthesis
Patient/Guardian Signature
Date
Remaining
Patient/Guardian Signature
Date
No
Yes (Complete 44)
32. Total Fee
B _________________
32. Total Fee
36. I have been informed
of the treatment plan and associated fees. I agree to be responsible for all
ANCIllARy ClAIm/TREATmENT INFORmATION
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly
to the below named dentist or dental entity.
1,000
16
17
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
39. Enclosures (Y or N)
(e.g. 11=office; 22=O/P Hospital)
38. Place of Treatment
law,unless
or the
treating
charges for dental services and materials not paid by my dental benefit plan,
prohibited
by dentist or dental practice has a contractual agreement with my plan prohibiting all
(Use “Place of Service Codes for Professional Claims”)
law, or the treating dentist or dental practice has a contractual agreementor
withamy
plan prohibiting
all charges. To the extent permitted by law, I consent to your use and disclosure
portion
of such
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
41. Date Appliance Placed (MM/DD/CCYY)
40. Is Treatment for Orthodontics?
of mywith
protected
of my protected health information to carry out payment activities in connection
this claim. health information to carry out payment activities in connection with this claim.
No (Skip 41-42)
2,500
20# (W)
18
AUTHORIZATIONS
AUTHORIZATIONS
20# (W)
15
31a. Other
Fee(s)
fold
35. Remarks
9
24
( ICD-9 = B; ICD-10 = AB )
34. Diagnosis Code List Qualifier
Quantity
Per Case
Laser-Cut Sheet (2012)
34. Diagnosis Code List Qualifier
fold
33. Missing Teeth Information (Place an “X” on each missing tooth.)
Paper/
Sequence
Item Description
Other
( ICD-9 = B; ICD-10 = AB )
New!A _________________
12001
Laser-Cut31a.Sheet
(2012)
Fee(s)
34a. Diagnosis Code(s)
C _________________
33. Missing Teeth Information (Place an “X” on each missing tooth.)
7
1200
New!
9
4
fold
23. Patient ID/Account # (Assigned by Dentist)
22. Gender
5
RECORD OF SERVICES PROVIDED
24. Procedure Date
(MM/DD/CCYY)
fold
Request for Predetermination/Preauthorization
6. Date of Birth (MM/DD/CCYY)
EPSDT / Title XIX
19. Reserved For Future
Use
18. Relationship to Policyholder/Subscriber in #12 Above
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Use the latest version of
the ADA Dental Claim Form
(If both, complete 5-11 for dental only.)
Dental
Form
5. Name Claim
of Policyholder/Subscriber
in # 4 (Last, First, Middle Initial, Suffix)
HEADER INFORmATION
17. Employer Name
51. SSN or TIN
52a. Additional
Provider ID
57. Phone
Number
(
)
58. Additional
Provider ID
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)
-
Secure records with the
ComplyRight™ Orthodontic
Case Analysis Envelo-File
Submit claims with ADA Envelopes
Safely store patient documents, plus record key
information and activity, with our ComplyRight™
Orthodontic Case Analysis Envelo-File. Record
key information right on the folder.
• Comes with security tint to meet HIPAA guidelines
• Accommodates up to 12 folded ADA Claim Forms
• Durable to sustain handling over time.
• Record key information right on the folder
Send your practice’s ADA claims and attending dentist’s
forms in convenient self-seal envelopes.
ADA Self-Seal Window Envelopes
Item #
Item Description
Quantity
Per Case
ComplyRight™ Orthodontic
Case Analysis Envelo-File
2003ES
41/8“ x 9" Version 2012, 2006 & 2004
500
2000ES
4" x 9" Version 2000
500
Item # A1048
1994ES
4½“ x 9" Version 1994, 90, 87, 85
500
Send form electronically
with the Speedy Claims
CMS-1500 Software
This easy-to-use software offers many great
features to allow you to fill in, print and even
store your CMS-1500 forms in a database.
• Get paid faster with the ultimate in CMS-1500 software!
• Back up data quickly and easily with
the built-in backup system
• FREE telephone support
• FREE updates
CMS-1500 Form Filler
Item #
Item Description
CMSCD12
CD Disc
CMSFD12
Flash Drive
System requirements: Windows® 98 through Windows 7,
32 or 64 bit. 128 MB RAM. 100 MB hard drive, any
processor above PII. Windows® 98 or higher.
Prevent processing delays with
CMS-1500 and UB-04 Jumbo Envelopes
As more insurance companies convert to
optically scanning your claim forms, the need
to mail them unfolded becomes increasingly
important. When claim forms are folded, they
may jam the automatic scanning equipment
and delay the processing of claims.
• Self-sealing window envelope holds
up to 50 unfolded forms
• Prevent processing delays
Jumbo Window Envelopes
Item #
Quantity
Per Case
Item Description
1500LR
9" x 12½" Right Window
CMS-1500
500
1500RS
9" x 12½" Right Window
CMS-1500 No Wording
500
1492LL
9" x 12½" Left Window UB-04
500
Jumbo Envelopes can be ordered in smaller quantities of 100.
Choose from two styles of
CMS-1500 Window Envelopes
Our traditional #10½ size envelope holds up to 12 claim forms.
• Available in either gum-seal or a self-seal style
• Must be ordered in case quantities
CMS-1500 Window Envelopes
Item #
Item Description
Quantity
Per Case
1500ES
4½“ x 9½“ Self Seal
500
1500E
4½“ x 9½“ Gum Seal
500