CMS 1500 Sample Fill In Survey Form for Claims Submissions

Complete 1 for each separate Case.You must include the CASE NAME after YOUR NAME when you type in each CMS survey form. (Ex: Smith, Peggy for Dover.) Utilize the CMS1500 Sample form located in Assignment 1 that you printed out to help you FILL IN this claim survey form.
Name: 


  1. Block 1: Insurance Type
    Medicare
    Medicaid
    Champus
    Champva
    Group Health Plan
    FECA Blk Lung
    Other


  1. Block 1a: Insured ID#


  1. Block 2:Patient's Name


  1. Block 3: Patient's DOB


  1. Block 4: Insured's Name


  1. Block 5 Patient's Address


  1. Block 6: Patient's Relationship to Insured
    Self
    Spouse
    Child
    Other


  1. Block 7: Insured's Address


  1. Block 8: Patient's Status
    Single
    Married
    Other
    Employed
    FT Student
    PT Student


  1. Block 9, 9a,b,c,d Other Insured's Name, Policy #, DOB, Sex, and Plan Name (Include all and be sure to LABEL each answer.)


  1. Block 10: Patient's Condition R/T
    a. Employment - YES
    a. Employment - NO
    b. Auto Accident - YES
    b. Auto Accident - NO
    b. State Initials Included from where accident took place
    c. Other Accident - YES
    c. Other Accident - NO


  1. Block 11, 11a,Sex,b,c,dInsured's Policy Group #, DOB, Sex, Employer, Insurance Plan Name, and IS THERE ANOTHER HELATH BENEFIT PLAN? (Answer YES or NO). Be sure to LABEL each.


  1. Block 12 Patient's Signature


  1. Block 13 Insured's Signature


  1. Block 14 Date of Current Illness


  1. Block 15 Similar Illness First Date


  1. Block 16 Dates unable to Work


  1. Block 17 Name of Referring Physician


  1. Block 17a ID of Referring Physician


  1. Block 18Hospitalization Dates from and to


  1. Block 19 Reserved for Local use


  1. Block 20 Outside Lab
    Yes
    No


  1. Block 21 DX Code(s) - List 1-, 2-, 3-, and/or 4- in front of each code when applicable


  1. Block 22Medicaid Resubmssion Code


  1. Block 23Prior Authorization Number


  1. Block 24A DOS from and to


  1. Block 24B POS


  1. Block 24C TOS


  1. Block 24D CPT/HCPCS Code and Modifier when applicable


  1. Block 24EDX Code Line Item


  1. Block 24F$Charges


  1. Block 24GDays or Units


  1. Block 24HEPSDT


  1. Block 24IEMG - Checked or Not Checked


  1. Block 24JCOB - Checked or Not Checked


  1. Block 24K Local Use - UPIN # of Physician Rendering Services


  1. Block 25 Federal Tax ID


  1. Block 26 Patient Account #


  1. Block 27Accept Assignment?
    YES
    NO


  1. Block 28Total Charge $


  1. Block 29 Amount Paid


  1. Block 30 Balance Due


  1. Block 31Signature of physician


  1. Block 32 Name and address of facility where services rendered other than home or office


  1. Block 33 Physician's suppliers Billing name, address, zip and telephone