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SaMPlE CMS 1500 ClaIM FORM

SaMPlE CMS 1500 ClaIM FORM

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[Music] this training is a walk-through of a completed cms 1500 outpatient claim form also known as a hikva 1500 form this is a sample claim for training purposes so none of the information we'll be using is real starting here at the top this is where you'll put the payers or the insurance providers information their name and claims address goes here if you notice we did not use any commas or decimal points because the national uniform claim committee who designed this form do not accept decimal points or commas box one this is where you'll indicate if it's medicare medicaid tricare champ va group fica or another type of claim we've selected group health plan because that is what most of your options will be this includes payers like blue cross blue shield united health care and cigna for this example we've entered abc healthcare in box 2 goes the patient's name the instructions direct us to write in a last name first name middle

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