Streamline Your Workflow with the Medical Bill Format PDF for Teams

Medical bill format pdf for teams

in today's video I want to show you how to complete a hicfa 1500 claim form this form is used by any non institutional health care provider to submit their claims the majority of the claims I submit are electronically but if I have to submit a secondary claim it will be on paper with the primary ELB so let's get started this claim is going to edna the type of insurance is for box one so we're going to select other since it's a commercial policy and then we'll fill in the member ID insured by d box 2 is the patient name and box 3 is patient date of birth and gender box 5 is the address and phone number box 6 patient relationship - in short in this example is self so one box for we're going to fill in her information again if the patient was not self insured if there was a guarantor of a different policyholder we would enter their information here but again this example is self so we're putting in her information Roxie insurance plan name e is there another health benefit plan in this example we're going to say no but if there were you would put you would select box yes and then over here in box 9d you would enter the insurance name [Music] okay in box 12 and 13 is an in-network plane so it's gonna be signature on file and the D okay the next couple boxes you would complete if applicable so 14 date of current illness injury or pregnancy LMP last menstrual period box 15 other date box 16 date patient unable to work in current occupation 17 name of referring provider 18 hospitalization dates related to current services 19 additional claim information 20 outside lab again you would complete those boxes if applicable box 21 is for the diagnosis and then you want to make sure you fill in the indicator ID which is zero for icd-10 in box 22 that's also 22 and 23 you complete those if applicable resubmission code and original claim number and prior authorization number box 24 is the date of service 24 beat place of service we're gonna select 11 for office D we would enter the cpt and modifier if applicable diagnosis pointer is a we only have one diagnosis F is going to be the charge number of units and the rendering provider NPI line 2 will enter another line item let's say she had an ultrasound as well same diagnosis actually let's give a bedight be ultrasound another diagnosis so for the diagnosis we're going to indicate be entered the charge unit and again rendering NPI box 25 is going to be the federal tax ID number and we'll select the ein box box 26 patient account number 27 accept assignment yes or no box 28 rs is the total charge 29 and 30 you can complete if applicable box 31 signature on file and the date box 32 service facility location information and box 33 billing provider information this is the group information I'll put in the group NPI here and that is how you complete a hicfa 1500 claim form