The HCFA form will print in red on a color printer.
The diagnostic codes appear on the HCFA form (field 21) in the order they were entered on the Transaction screen.
The current HCFA form is CMS-1500 (08-05). The format of the information on this form is based on their specifications. For example, based on their specifications, the telephone number does not include hyphens, and the lab charge in field 20 does not include dollar signs or decimals. Commas are used to separate the last name, first name, middle initial. Commas, periods, or other punctuation are not shown in address fields.
Form 1500 (08-05) accommodates the mandated National Provider Identifiers (NPI#’s).
Diagnostic codes are linked to medical codes through the Diagnostic/Treatment Code Linking feature. Field 24-E on the HCFA form can only be filled in by using this feature.
After you select medical codes from the insurance selection window, the HCFA form will open.
The OPTIONS button at the top of the HCFA form window allows you to change the following:
- The Federal Tax ID number for the doctor can be marked as either SSN or EIN
- The Billing Name can be marked as Practice or Provider. If you mark Provider, the form will default to the Provider shown on the Patient Information screen for this patient. You can select a different Provider from the HCFA Form screen by clicking on the gray box at the Billing Provider field.
- The Insurance Payment can be marked as Signature on File, Payment to Patient, or Blank.
- You can select the Number of Copies you would like to print.
The following information is on the HCFA form screen:
These types of claims can be selected – Medicare, Medicaid, TRICARE/Champus, Champva, Group Health Plan (this is the default), FECA Blk Lung, and Other.
- Claim To – InsPlan 1 and InsPlan2 (if available),
- Patient Status – Single (this is the default), Married, Other, Employed, Full-Time Student, Part-Time Student
- Accept Assignment? (for government claims) – Yes or No
- Is there another Insurance Plan? – Yes or No. This will be marked as “Yes” if the patient is covered by another insurance plan.
- Is patient’s condition related to – Employment, Auto Accident, Other Accident. There are Yes or No choices at each of these fields.
- Click the gray buttons to open the calendar if you need to enter dates at any fields, such as “Date of current illness or injury”. Note: These dates will appear in an 8 digit format due to HCFA specifications.
- Billing Provider – This is the title of the field if you selected “Provider” as the Billing Name in Options.
- This will default to the provider name on the Patient Information screen. You can change the provider by clicking on the gray box to select from the provider list. The Billing Provider information and phone number will appear in field 33 on the HCFA form.
- The Billing Provider NPI# will be shown based on the National Provider ID# from their Provider Information screen. The Billing Provider NPI# will appear in field 33a on the HCFA form.
- Billing Practice – This is the title of the field if you selected “Practice” as the Billing Name in Options.
- The Billing Practice name will default to the employer name for the provider on the Patient Information screen for the current patient. The Billing Practice information and phone number is shown in field 33 on the HCFA form.
- If you click on the gray box at this field to select a different provider, the Billing Practice name will not change unless the selected provider has a different employer name. Note: If you want the provider name to be shown in this field, you must click on the Options button and mark “Provider” next to Billing Name.
- The Group NPI# can be typed in the Billing Practice NPI field (this is the only way to enter the Billing Practice NPI#). This field is only shown if you have select “Practice” next to Billing Name in Options. The number will be saved for this Billing Practice name. The Billing Practice NPI# is shown in field 33a on the HCFA form.
- Name of Referring Provider – Click on the gray box at this field to select from the Physician database list.
- Referring Provider NPI – The NPI# can be typed directly in the Referring Provider NPI field, and it will be saved for this Referring Provider.
- This is the only way to enter an NPI# for the Referring Provider.
- The Referring Provider NPI# is shown in field 17b on the HCFA form.
- Name and address of facility where services were rendered – Click on the gray box to open the Employer database list. Select the employer name for your practice. This information appears in field 32 on the HCFA form.
- Facility NPI – A Facility NPI# can be typed directly on this field.
- It will be saved for the selected employer name.
- This is the only way to enter a Facility NPI#.
- The Facility NPI# is shown in field 32a on the HCFA form.
- Note: NPI#’s for the Referring Physician, Billing Practice, and Facility can only be entered from the HCFA claim screen. All NPI#’s entered on the HCFA form are saved. If you change an NPI#, MOGO will ask if you want to save the changes.
Tip: Click on the Envelope button at the top of the HCFA form screen to print an insurance envelope. There are buttons on the envelope screen to print an envelope for the patient’s home, business, referral, and physician, insurance, and pharmacy.