CMS-1500 Form

CMS-1500 Form

UB-04 Form

FDA Approval Letter

Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied. Below is the downloadable CMS-1500 form designed to facilitate successful claim submissions. Examples of claim forms and potential codes that may be appropriate when billing for Cathflo and related services are included as well.

Note: Select the appropriate billing code when filing all claims. Billing codes should be based on diagnosis and the services provided.

Example of CMS-1500 (PDF)

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How to complete the CMS-1500

The CMS-1500 is used by physicians, durable medical equipment suppliers, and other providers to bill Medicare, Medicaid, CHAMPUS, VACHAMPUS, Group Health Plan, FECA Black Lung, or other types of insurance. In rare instances, some insurance companies may request free-standing clinics and hospitals to submit charges with the CMS-1500 form.

All providers billing with the CMS-1500 must provide specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and Healthcare Common Procedure Coding System (HCPCS). The number of services rendered and the charge for these services depends on the facility's charge master.

The submission criteria for completing the CMS-1500 form may vary. To ensure all local submission criteria are met, providers should contact their representative before submitting claims.