How to Fill Out an HCFA Form

There are two primary standard claims forms used by Medicare and commercial insurers; the CMS 1500 and the UB-04. These forms, once called HCFA forms, are used for by doctors, facilities, hospitals and individuals to receive payment for health services. The CMS 1500 is primarily used for office visits, while the UB-04 is used for inpatient admissions, home health and nursing facility services. Each form requires certain standard information to be accepted for payment. Claim forms may be submitted electronically or by hard copy to the insurer.

CMS-1500 InstructionsStep 1

Complete the form with the type of patient’s coverage, patient’s identification number and patient name, address, city, state and ZIP code. Other information required includes patient date of birth, marital status and whether or not the service requested for patient is relevant to their employment or an accident.

Step 2

Fill in the sections about the insured primary and secondary insurance coverage. Line 12 requests the patient’s signature. If the patient’s signature cannot be obtained, input “Signature on File” in this block.

Step 3

Enter the name of the referring provider or other source if applicable. Standardized industry diagnosis codes are entered on line 21. Many health plans require prior authorization for services, and if this information is known, it can be entered on line 23.

Step 4

Complete section 24, which includes: dates of service, place of service, whether or not services were rendered in an emergency, procedure codes, provider charges, number of days or units if applicable, and provider ID. This information has standardized codes Services entered on line 24 must correlate with the information entered on line 21 and have standardized codes.

Step 5

Fill in the last sections with the provider’s federal tax ID, total charges from line 24, amount paid from other insurers and the balance due from Medicaid or the health plan the claim is being sent to, address services were rendered and billing provider’s name, address, phone number and ID number.

UB-04 Instructions

Complete the form with the billing provider’s name, address, telephone number and pay-to name and address.

Input the patient control number. This required field is a patient’s unique ID assigned to the patient by the hospital.

Enter the three-digit code for type of bill on line 4. This field is required to process a claim, as is line 6, in which services rendered from-through dates of the admission or accommodations being billed.

Input the patient’s name, birth date, admission date and hour, type of visit, referral source, and discharge status. Other fields such as condition codes, occurrence codes, value codes are required only if applicable to the claims.

Enter the appropriate four-digit revenue code on line 42. For outpatient claims line 43and 44 are required. Complete the remaining sections with: date bill was created, units of services, total charges and non-covered charges (optional).