Below is a link to HMSA's interactive version of the CMS 1500 claim form. The document includes instructions applicable to all HMSA lines of business. Adobe Reader or another PDF-reader application is required to view the document. Please note that providers may not submit claims on printouts of the interactive form. Any claims submitted on printouts of the interactive form will be rejected.
To view the instructions for a particular CMS 1500 block, simply click on the block number. A text window containing the block's instructions will appear on your screen. Instructions also appear, in a truncated format, anytime you move the cursor over a field number. However, clicking on the field number displays the instructions in a more user-friendly way.
If you wish, you can move a block's instructions window by clicking at the top or bottom and dragging (moving the mouse while holding down the left mouse button). To resize the window, click in the lower right corner and drag. Any changes you make will be retained until you close the PDF-reader application.
The following instructions are applicable to CMS 1500 claims filing for HMSA's basic plans and 65C Plus. The numbers on the left refer to the fields on the claim form. Indicators are also included that designate whether the field is (R)equired, (C)onditionally required, (O)ptional or (N)ot applicable for HMSA claims processing.
|Required||The information must always be provided. Claims submitted with the information missing may be returned to the submitter or there may be a processing delay while the information is obtained.|
|The information must always be provided when the condition is present. Claims submitted with the information missing may be returned to the submitter or there may be a processing delay while the information is obtained.|
|Optional||The information is helpful but not necessary for prompt processing.|
|Not Applicable||The information is not used.|
To view previous versions, see:
CMS 1500 Claim Form - Differences Between HMSA Plans and Out-of-Area Plans - OBSOLETE (Home IV Therapy version)
|Rev#:||Date:||Nature of Change:|
|2.0||12/28/2006||This document updates and consolidates previous versions, which displayed instructions in a conventional text format.|
|2.1||10/04/2007||Made minor, non-substantive text edits.|
|2.2||10/18/2007||Fixed spacing around hyperlink.|
|2.3||03/20/2014||Added a new link to the cms 1500 2012 form version.|
|2.4||01/08/2015||Added the following: "Please note that providers may not submit claims on printouts of the interactive form. Any claims submitted on printouts of the interactive form will be rejected."|
|2.5||01/06/2016||Removed link to obsolete form.|
|2.6||05/04/2016||Revised 2nd sentence to read: The document includes instructions applicable to all HMSA lines of business.|
Files that are in PDF format can be viewed using the free Adobe Reader or another PDF-reader application.
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