Sample CMS-1500 Claim Form for Office Billing: KEYTRUDA

Document technical information

Format pdf
Size 652.6 kB
First found Jun 9, 2017

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

Organizations

Places

Transcript

Sample CMS-1500 Claim Form for Office Billing:
KEYTRUDA® (pembrolizumab) for Injection 50 mg
CARRIER
Note:
for and
questions
on billing if a portion of a package is wasted, consult the applicable payor’s policy regarding wastage.
Save
Print Options
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
PICA
MEDICARE
MEDICAID
TRICARE
CHAMPVA
(Medicare#)
(Medicaid#)
(ID#/DoD#)
(Member ID#)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE
MM
DD
YY
5. PATIENT’S ADDRESS (No., Street)
OTHER 1a. INSURED’S I.D. NUMBER
FECA
BLK LUNG
(ID#)
GROUP
HEALTH PLAN
(ID#)
(ID#)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX
M
F
7. INSURED’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
Self
CITY
STATE
Spouse
Child
Other
8. RESERVED FOR NUCC USE
(
STATE
CITY
TELEPHONE (Include Area Code)
ZIP CODE
(For Program in Item 1)
TELEPHONE (Include Area Code)
ZIP CODE
(
)
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
MM
DD
YY
YES
NO
b. RESERVED FOR NUCC USE
b. AUTO ACCIDENT?
c. RESERVED FOR NUCC USE
c. OTHER ACCIDENT?
PLACE (State)
YES
Box 19
F
b. OTHER CLAIM ID (Designated by NUCC)
NO
c. INSURANCE PLAN NAME OR PROGRAM NAME
YES
d. INSURANCE PLAN NAME OR PROGRAM NAME
SEX
M
NO
10d. CLAIM CODES (Designated by NUCC)
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
Enter the following:
YES
NO
If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON’S SIGNATURE I authorize
• Drug name: [KEYTRUDA
(pembrolizumab)]
12. PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
• Route of administration
below.
Box 21
• NDC: 0006-3029-02
SIGNED
DATE
SIGNED
EnterMMappropriate
ICD-9-CM
diagnosis
code(s)
DATE
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER•
16. DATES
PATIENT UNABLE
TO WORK IN CURRENT OCCUPATION
• The dosage provided
MM
YY
DD
YY
DD
MM
DD
MM
YY
DD
YY
QUAL.
TO
FROM
QUAL.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
DD
MM
YY
YY
FROM
TO
17a.
17b. NPI
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
20. OUTSIDE LAB?
YES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
A.
E.
I.
24. A.
MM
YY
B.
C.
PLACE OF
SERVICE EMG
CODE
ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
H.
L.
K.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
Box 24 E$ CHARGES
NO
• Record
the relevant diagnosis pointer from Box 21
22. RESUBMISSION
D.
G.
F.
J.
DATE(S) OF SERVICE
From
To
YY
MM
DD
DD
ICD Ind.
C.
B.
E.
DIAGNOSIS
POINTER
G.
F.
$ CHARGES
DAYS
OR
UNITS
H.
J.
RENDERING
PROVIDER ID. #
I.
EPSDT
ID.
Family
Plan QUAL.
1
NPI
2
NPI
25. FEDERAL TAX I.D. NUMBER
SSN EIN
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
NPI
Box 24 D
NPI
• U
se the appropriate unspecified HCPCS code toNPI
bill for27.KEYTRUDA
(pembrolizumab)
ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
26. PATIENT’S ACCOUNT NO.
$
$
YES
NO
• The infusion time corresponds to CPT code
96413
( For
NPI
NUCC Instruction Manual available at: www.nucc.org
30. Rsvd.for NUCC Use
govt. claims, see back )
32. SERVICE FACILITY LOCATION INFORMATION
a.
Box 24 G
• W
hen using an unspecified HCPCS code, enter
only 1 unit inNPI
this field
3
• When using an unspecified HCPCS code, enter
4
the NDC 0006-3029-02,
preceded by “N4,” in this
gray space 5
6
PATIENT AND INSURED INFORMATION
1.
PHYSICIAN OR SUPPLIER INFORMATION
www.nucc.org
b.
PLEASE PRINT OR TYPE
33. BILLING PROVIDER INFO & PH #
a.
NPI
(
)
b.
APPROVED OMB-0938-1197 FORM 1500 (02-12)
Layout by Fiachra Forms http://fiachraforms.com/quickstart_CMS1500_PDF.html
The suggestions contained on this form are compiled from sources believed to be accurate for the Medicare Part B program, but Merck makes no representation that the
information is accurate or that it will comply with the requirements of any particular Medicare Administrative Contractor (MAC) or payor. You are solely responsible for
determining the billing and coding requirements applicable to any payor or MAC. Diagnosis codes should be selected only by a health care professional. The information
provided here is not intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Billing and coding requirements may
vary or change over time, so it is important to regularly check these requirements with each payor or MAC. Merck and its agents make no warranties or guarantees, express or
implied, concerning the accuracy or appropriateness of this information for your particular use and caution that changes in public and private payor billing requirements occur
frequently. The use of this information does not guarantee payment or that any payment received will cover your costs.
ONCO-1108274-0009 08/14

Similar documents

×

Report this document