How Do I Fill Out an HCFA-1500 Form?

How Do I Fill Out an HCFA-1500 Form?
The HCFA-1500 form is used to bill for most outpatient services.

Step 1

Determine the type of insurance coverage the patient has. The patient may have more than one insurer. Use line 1 to codify that Medicaid is the only insurer or primary insurer; or that the patient receives Medicare with supplement benefits from Medicaid; or that there is a third-party insurer.

Step 2

If Medicaid is the only insurer or primary insurer, use lines 1A, 2,3,5 and 10 to identify the patient. Complete line 11D to code that Medicaid is the primary insurer with supplement coverage from another insurer.

Step 3

Complete lines 14 and 16 to record the date of illness. Use lines 17 and 17a to record the physician's information. Then, use lines 18 and 20 to record if the services were rendered at a hospital or lab.

Step 4

Complete line 21 to record the ICD-9, or diagnosis code. Record the prior authorization number in box 23, if prior authorization was required.

Step 5

Complete lines 24A to G to record date, place and type of service. Also record the CPT or procedure code, the reference number of the diagnosis code, charges, and days or units of service.

Step 6

Use line 28 to record total charges. Complete line 29 to record the amount paid by the patient and line 30 to code the balance due.

Step 7

Record the physician's information on lines 31 to 33.

Step 8

If the patient receives any type of coverage from Medicare or if a third-party insurer is the primary insurer, complete lines 1A, 4, 7, 10D, 11 (C and D), 29 and 30.

Step 9

If the patient receives coverage from Medicaid, Medicare and a third-party insurer, complete the same lines as in Step 8.