Since 92 percent of Americans have health insurance according to Statista, medical billing is inevitably part of a practice’s everyday tasks. Sure, most practitioners didn’t get into medicine to file paperwork all day, but the Health Care Financing Administration (HCFA) form ― the primary medical claim form ― is relatively easy to complete. This guide will tell you all about the form and how to fill out and file it.
What is the HCFA form?
The HCFA form, also known as Form HCFA 1500 or Form CMS-1500, is what noninstitutional practitioners file to payers (insurance companies). They often comprise the basis of medical claims.
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The HCFA 1500 has official origins. It’s the work of the Centers for Medicare & Medicaid Services (CMS), which initially devised it to facilitate Medicare and Medicaid reimbursements.
Form HCFA is so comprehensive that private insurers have also adopted it as their standard. Additionally, federal law requires practitioners seeking reimbursement to file either these forms or UB-04 forms, which we’ll explain later in this article.
How does the HCFA form work?
Practitioners like yourself (or, more realistically, your front-office staff or third-party medical billing team) will complete the HCFA form after a patient encounter. A complete HCFA form will include Current Procedural Terminology (CPT) codes for all services provided. It may also include International Classification of Diseases, 10th Revision (ICD-10) codes for diagnoses. These codes standardize services, so payers more easily know what to reimburse.
Your HCFA form should also include your patient’s demographics and basic information. Just as importantly, the form should clearly state your patient’s insurance information. This way, payers know exactly which of your CPT and ICD codes they can and can’t reimburse.
Who fills out an HCFA form?
Any of these kinds of individual practitioner can complete and file HCFA forms:
- Nurse practitioners
- Certified nurse anesthetic practitioners
- Physician assistants
- Clinical psychologists
- Clinical social workers
- Ambulance services
- Laboratory services
Only noninstitutional healthcare providers should fill out the HCFA form. Other providers must use Form UB-04.
What is included in an HCFA form?
The HCFA form is made up of 33 boxes. If that seems like an overwhelming number, fret not ― each box requires little information, most of which is rudimentary. Plus, we’ve prepared the following billing guide to HCFA so that you can breeze through the process. Each numbered entry in this guide corresponds to the same box number on the HCFA form:
- Insurance information: Indicate Medicaid, Medicare or the patient’s private insurer alongside their insurance ID, which goes in box 1a.
- Patient’s name: Write the patient’s full legal name.
- Patient’s sex and date of birth: Write the month, date and year as two digits each. Check the appropriate box for the patient’s sex assigned at birth.
- Insured’s name: If the patient is using their own insurance plan, you can leave this box blank. If their plan is in someone else’s name, write that name here.
- Patient’s address and phone number: Fill out each box in this section with the appropriate information.
- Patient’s relationship to insured: Check the appropriate box. You should only check one of the four boxes present.
- Insured’s address: Again, leave this box blank if the patient is self-insured. Otherwise, add this information for the person whose name is on the insurance plan.
- Patient status: Check one box in the first row (marital status) and one box in the second row (employment status).
- Other insurance information: Leave this section blank if the patient has only the primary insurance indicated earlier on the form. If the patient has secondary insurance, include all requested information here.
- Patient condition and Medicaid information: Here, indicate whether the services you provided were in response to injuries or illnesses sustained on the job, in a car accident or in another kind of accident. In the “reserved for local use” box, add the patient’s Medicaid number if they have one.
- Insured’s policy or group number: Here, write down the patient’s policy, group or Federal Employees’ Compensation Act number. You should also include the identifying information requested. If you’ve added information to box 9, check “yes” in box 11d.
- Patient’s signature: All HCFA forms require a patient’s signature to submit. This box is where you’ll record that signature.
- Insured’s signature: You only need to complete this section if the patient has secondary insurance, as indicated in box 9.
- Date of condition being treated: Write the date when the patient first began experiencing symptoms.
- Previous reports of condition being treated: If the date of the patient encounter you’re billing for isn’t the patient’s first instance of this condition, record the first date here instead. You should write the date of the encounter you’re billing for if this is indeed the patient’s first time with symptoms.
- Dates out of work: If the patient’s condition has put them out of work, include the dates the patient has been sidelined.
- Referring provider: If another practitioner referred the patient to you, list that practitioner’s name, ID number and National Provider Identifier (NPI).
- Hospitalization dates: If the patient’s condition has led to their hospitalization, list the hospitalization dates here.
- Reserved for local use: Leave this section blank for the recipient of the form should they need it.
- Outside lab charges: If you’re filing a claim for third-party lab tests, check the “yes” box and write down the charge amount.
- CPT codes: List the CPT codes corresponding to the services provided. You can use the page-width lines under “Diagnosis Pointer” to provide additional codes.
- Medicaid resubmission code: If you’re resubmitting a rejected claim to Medicaid, write the original claim’s reference number here.
- Prior authorization number: If your patient brought prior authorization from the payer to their appointment, add the authorization number here. You’ll also need a seven-digit IDE number for investigational devices and a ZIP code for ambulance services.
- Service details: Here, you’ll list the dates and location of service, the services provided and the corresponding charge amounts. You’ll also complete the diagnosis pointer section you first encountered in box 21. Note that you can leave this box blank for influenza or pneumococcal vaccines.
- Tax identifier: Provide your employer identification number (EIN) or, if you’re a sole practitioner with no EIN, your Social Security number.
- Patient account number: Though completing this box is optional, writing your patient’s account number within your practice can help you link the claim with the patient and track progress accordingly.
- Accept assignment: Check the “yes” box for physician, laboratory, surgical, supplier or ambulance services.
- Total charges: Write the total amount of reimbursement you’re seeking.
- Amount paid: If part of the claim has already been paid, indicate that amount here.
- Balance due: Subtract the value in box 29 from box 28, then write that amount here.
- Provider signature: Sign your HCFA form here.
- Service facility location information: Write the full address of the location where services were provided.
- Service provider information: Here, list your address again alongside your NPI and phone number. You’re now done with your HCFA form.
How to file an HCFA form
Once you’ve completed your form, you should run it through a claim scrubber to check for any errors. These tools are usually available through third-party medical billing service providers. Once you fix the indicated errors, you can resubmit your HCFA form to an appropriate clearinghouse, which will deliver it to the appropriate payer.
Run your HCFA form through a claim scrubber to identify errors that could result in claim rejections.
What is the difference between UB-04 and HCFA?
While individual, noninstitutional practitioners file HCFA forms, institutional practitioners submit Form UB-04. This distinction means that hospitals, inpatient facilities, nursing facilities and other medical facilities use Form UB-04. All other practitioners use Form HCFA instead.
This boundary between Form UB-04 and HCFA is admittedly a bit vague. However, medical billing experts completely understand the difference. Better yet, the medical billing experts who work at third-party medical billing companies (see our AdvancedMD review for an example) can complete and file these forms on your behalf.
If you’d prefer to avoid the headache of choosing the right forms and spending time on paperwork, visit our medical billing best picks page. There, you’ll find our recommendations for third-party medical billing services based on your practice size, specialty, billing complexity and other factors. The medical billing process can be tedious, but with outsourced medical billing, it becomes significantly easier.
Healthcare has gone digital. You can complete and store forms like the HCFA in the best electronic medical records software, which provides a digital archive and also allows you to transmit data to payers and other healthcare facilities.
Filing medical claims means understanding HCFA
Medical practices live and die based on how their claims are paid by insurance companies. The form HCFA is a central part of this process. Ensuring your forms are filled out completely and accurately is a key step to making sure your claims are processed and paid in a timely manner, which could make the difference between your practice’s success and failure.