Paper Forms & Instructions

NOTE:

In July 2001, the Health Care Financing Administration (HCFA) became the Centers for Medicare & Medicaid Services (CMS). Because of this name change, the prefix of form numbers that had been 'HCFA" is being changed to "CMS." Visit www.cms.hhs.gov/forms for more information.

Form CMS-1500:

The CMS-1500 form and instructions are used by non-institutional providers and suppliers to bill Medicare, Part B covered services. It is also used for billing some Medicaid covered services. Please contact your Medicaid State Agency for more details. If you do not know the telephone number for your Medicaid State Agency, please go to Medicaid State Agency Contact List.

II. Use this link to obtain an electronic copy of Form CMS-1500

III. To obtain a copy of the CMS-1500 instructions (Updated November 1998) for Medicare, Part B claims:

For current instructions, use this link.

IV. For a copy of Place of Service (POS) codes used on Form CMS-1500, please go to http://www.cms.hhs.gov/states/poshome.asp

Important Note: The CMS-1500 instructions include changes for the National Provider Identifier (NPI) and National Plan Identifier (NPlan ID). The NPI and NPlan ID have not yet been implemented. We are not able to predict their effective dates.

You should ignore any revisions made to the CMS-1500 instructions for NPI and NPlan ID and continue processing claims under previous instructions. CMS will notify Medicare carriers in the future when the CMS-1500 reporting requirements for NPI and NPlan ID will be effective, including any additional changes.

Form HCFA-1450 (UB-92):

The UB-92 form and instructions are used by institutional and other selected providers to complete a Medicare, Part A paper claim for submission to Medicare Fiscal Intermediaries. The paper UB-92 (Form HCFA-1450) is neither a government printed form nor distributed by the CMS. The National Uniform Billing Committee is responsible for the design of the form. You may obtain copies of the paper UB-92 (Form HCFA-1450) from the Standard Register Company, Forms Division. Their phone number may be found in your local yellow pages.

I. Go to Form HCFA-1450 (UB-92) to obtain an electronic copy.

II. Use this link to obtain printing specifications for Form HCFA-1450 (UB-92).

III. To link to a copy of the most recent Form HCFA-1450 (UB-92) instructions
    (266K PDF).

IV. CR 3012, Pub. 100-04, Rev. 81, Update of UB-92 Codes
    (120K PDF).

Form CMS-1491:

The CMS-1491 (Request for Medicare Payment-Ambulance) form and instructions is used to bill Medicare, Part B covered ambulance services. Please note that Medicare, Part B covered ambulance services can be billed on Form CMS-1500 too. Form CMS-1491 is available for free at any local Social Security Office or Medicare carrier. For a list of Medicare carriers in your State, including their telephone number, please go to the Intermediary/Carrier Directory Homepage.

Use this link to obtain an electronic copy of Form CMS-1491 (34K PDF).

Form CMS-1490S:

The CMS-1490S (Patient's Request for Medicare Payment) form and instructions is used only by Medicare beneficiaries for billing Medicare covered services. Please note that providers and suppliers are required by law to submit Medicare claims on behalf of the beneficiary. If the beneficiary wishes to submit a claim, they must do so on Form CMS-1490S. The beneficiary must also attach to Form CMS-1490S any bill(s) they receive from providers/suppliers. This form is available for free at any local Social Security Office or Medicare carrier. For a list of Medicare carriers in your State, including their telephone number, please go to the Intermediary/Carrier Directory Homepage."

Link here to obtain an electronic copy of Form CMS-1490S (16k PDF).

EDI Enrollment Form

The CMS Standard EDI Enrollment Form must be completed prior to submitting electronic media claims (EMC) to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC.

Each new EMC biller must sign the form and submit it to their local Medicare carrier or fiscal intermediary. Any existing EMC billers who have not completed the CMS Standard EDI Enrollment Form must complete and sign this form and submit it to their local Medicare carrier or fiscal intermediary also. For more information regarding the CMS Standard EDI Enrollment Form,Please go to the Carrier EDI Helpline Phone Numbers" or the Fiscal Intermediary EDI Helpline Phone Numbers" for a list of EDI Helpline telephone numbers.

An organization comprising of multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is to be held responsible for the performance of its components.

Use this link to obtain a electronic copy of the CMS Standard EDI Enrollment Form (24k PDF).