What Is HCFA in Medical Billing? | Medical Billing Service Review (2024)

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There are specific protocols when billing with insurance companies. One of those protocols is filling out form HCFA. Here’s what to know about this form.

The Health Care Finance Administration(HCFA)form is a claim form used in settlement of government insurance programs such as Medicare and Medicaid to medical providers. Developed byThe Center of Medicaid and Medicare (CMS)but was adopted as a standard form by all Insurance plans.

Clinical practitioners and physicians use the HCFA to submit claims for professional services. Federal regulations require all healthcare providers to use the HCFA or UB-04 form for filing claims.

Keep on reading to learn more!

The HCFA/CMS-1500

This form is universal, and all healthcare providers use them to bill health insurance providers. Both Medicaid and Medicare, part B services, are billed using this form. The National Uniform Claim Committee (NUCC) maintains this form.

The HCFA contains all the essential info required to submit a precise claim. In this form, the healthcare provider should include the following;

  • Patient’s demographic information
  • Patient’s insurance information
  • Medical Codes
  • Dates of service

The information filed in this form should be accurate and factual. To avoid disputes, healthcare providers should be truthful when filling the form. In case the insurance detects irregularities, they may fail to honor the claims.

There is a specific box that applies to each health provider. The payer might provide different info on how to fill some boxes. The medical coder and biller must be familiar with some specific payer requirements.

How Does the HCFA Form Work?

Firstly, the healthcare provider treats a patient and then sends the bill of services to the designated payer. Usually, the designated payer is the insurance provider. The insurance provider evaluates the claims and determines the services to reimburse.

When the healthcare providers offer the services to the patients, they record the services using the appropriatemedical codes. CPT codes apply for various treatments while ICD codes apply for diagnosis. These codes provide a summary of services offered by the provider.

Also, the patient’s insurance information and demographic data are added to the bill. It is after this when the claims get processed.

Who Can Fill Insurance Claims Using the HCFA?

Individual healthcare physicians and not institutions can only fill this form. Below are some of the people who can fill the form;

  • Clinical psychologists
  • Nurse practitioners
  • Physician practitioners
  • Ambulance services
  • Diagnostic laboratory services
  • Nurse Midwives
  • Physician assistants
  • Certified nurse anesthetics
  • Clinical social workers

Only non-institutional healthcare providers should submit insurance claims using the HCFA form. Institutional providers should submit applications using the UB-04 form.

Filling the Claims

For the insurance claims to be met, some set industry standard and protocols have to be met. The medicalbillers use softwareto record patient data, prepare the claims, and submit to the appropriate insurance provider. However, there is no universal software that the biller must use.

All insurance billing software uses a set of standards set bythe HIPAA and the Code Set Rule (TCS). The insurance claims can be filled manually on paper or electronically. Many healthcare providers prefer the electronic system to the manual one.

The electronic system is faster and more accurate compared to the manual one. However, the medical provider should be well versed with both methods.

Rules for Filling the HCFA Form

The HCFA form should be filled according to the provisions of the law. The claims can be rejected if the form is not correctly filled. You can avoid rejection of the claims by doing the following;

  • Fill all data accurately and precisely in the specific fields
  • Use the address for the service facility
  • Include NPI information where required
  • Use the correct procedure and diagnosis codes
  • Enter the patient’s insurance information

The insurance providers need accurate data.

How to Fill the HCFA Form

How the biller fills the HCFA form determines whether or not the insurance provider will offer compensation. The HCFA has 33 boxes that you must fill. Below is a detailed guide on how to fill each detail

1. Type of Payer

In this part, you mark the type of health insurance coverage, i.e. Medicare or Medicaid. Also, enter the patients’ insurance number.

2. Patient’s Name and Gender

Enter the full patient’s name, as shown in the Medicare Card. This section allows entry of up to 28 characters.

3. Birthdate

In this box, the medical provider should include the patient’s date of birth and gender. Use the 6-digit or 8-digit format.

4. Name of the Insured

Enter the name of the insured if not the patient. It can be spouse employment or any other primary. Leave blank if the patient is the one insured.

5. Physical Address

Enter the patient’s address and zip code. The first line is for street address, city, and state on the second line and zip code on the third line.

6. Patient’s relation to the insured

Mark one box showing the relationship of the insured, whether spouse, child, etc. Mark the corresponding on the form.

7. Insured’s address

Enter the insured’s city, state, zip code, phone number, and address. If unknown, leave the physical address details blank. Use employer’s address for worker’s compensation.

8. Patient Status

Fill the general status of the patient. Status includes; worker, student, employed, and marital status.

9. Other Insured’s Details

Include there exists additional health coverage for the insured, add in this column. That consists of the extra health coverage details, personal details, employers detail, school, etc.

10. Reserved for Local Use

This part is preserved for Medicaid information. Enter the patient’s Medicaid number if available.

11. FECA Number/Insured’s Policy Group

Input the insured’s group number or policy as written in the ID card. This proves that the physician made an effort of determining whether it’s primary or secondary Medicare.

12. Patient’s Signature

The patient should sign on the file. If the patient is debilitated, then an authorized representative should sign or enter a 6-digit/8-digit alphanumeric date. If a representative signs, the reasons should be indicated on the line followed by the representative’s relationship and personal details.

13. Insured’s Signature

If the Medigap info is included in section 9, the insured is supposed to authorize the payment by signing in this section. A signature on file is the most appropriate for this section.

14. Date of Illness

When did the patient get ill? The biller should enter the exact date of illness, pregnancy, or illness.

15. Other Dates

Fill this information if the box 10b and 10c are checked. Use a 6-digit or 8-digit to enter the date of a related patient’s condition.

16. Date of Incapacitation

In this section, enter the date in which the patient was unable to work in the current occupation. This section applies if the patient is unemployed but unable to work.

17. Name of Referring Physician

This section applies if another physician referred the patient. Enter the full names, ID number, and NPI number of the referrer.

18. Hospitalization Dates

If the patient was hospitalized, enter the date of hospitalization. You could leave blank if there was no hospitalization needed.

19. Additional Claim Information

The biller should enter the date when the physician’s NPI saw the patient. The payer assigns the identifier to identify the provider uniquely.

20. Outside Lab Charges

The biller should fill this section when billing for diagnostic tests. Mark ‘yes’ if another party other than the provider is offering the service.

21. Patient’s Diagnosis Condition

All health providers, except ambulance services, should enter a patient’s diagnosis specificity using special codes. The codes should be accurate and correct.

22. Medicare Resubmission Code

Enter the original reference number in case of resubmitted claims. This section does not apply for original claim submission. Leave this section blank for Medicare

23. Prior Authorization Number

If the medical procedures require QIO approval, enter the QIO prior authorization number. If an investigational device, enter the 7-digit IDE number. For ambulance services, provide the 5-digit zip code of pickup point.

24. Details of Service

In this section, the biller should include the following;

  • Dates of service
  • Place of service
  • Services or procedures
  • Charge amount
  • Diagnosis Pointer
  • Units/days of service

The above sections do not apply for pneumococcal or influenza vaccine.

25. Federal Tax ID Number

Enter the details of the provider of service (EIN or SSN). This is the unique number used for reporting taxes.

26. Patient’s Account Number

Enter the patient’s number provided by the service provider. This part is not mandatory as it helps the provider to identify the patient.

27. Accept Assignment

Tick the appropriate box to agree to the assignment benefits. Assignment benefits include the following;

  • Supplier/physician services
  • Laboratory services
  • Surgical services
  • Ambulance services

Be sure to select options that only apply to your case.

28. Total Charge of services

The biller should enter the charge of services. Insurance providers require realistic and unexaggerated charges.

29. Amount Paid

The biller should enter the amount paid for the covered services. This does not include discounts.

30. Balance Due

Leave this section plank. Medicare does not need you to fill this section.

31. Signature of the Healthcare Provider

The physician or non-physician offering the service should enter a signature file. The current dates should follow the provider’s signature.

32. Facility Zip Code

Enter the location of the physician’s facility zip code. This applies for services payable under the provider’s fee schedule.

33. Billing Provider NPI and Taxonomy

The biller should enter the facility’s NPI. In this section, the biller should enter their name, address, zip code, and phone number. This is the final section and identifies that the provider is requesting payment for the rendered services.

The Bottom Line

As evident in the above, filling the HCFA form is not an easy task. Inexperienced health care providers should ask for professional medical billing help to avoid messing up and missing out on claims.

If you’re looking for medical billing services,be sure to get quotesfor a better comparison.

What Is HCFA in Medical Billing? | Medical Billing Service Review (5)

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Mike Cynar brings buyers and sellers together by producing reviews and creating non biased webpages allowing users to share their experiences on various products and services. He and his staff write informative articles related to the medical field, legal, and other small business industries.

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What Is HCFA in Medical Billing? | Medical Billing Service Review (2024)


What is the most current HCFA 1500 form? ›

LATEST APPROVED VERSION FORMS: CMS/HCFA 1500 claim forms (02/2012 version) are the currently approved forms that replaced (version 08/05) CMS-1500 Forms; required for health care providers to bill a patient's insurance company for reimbursem*nt of medical claims.

Which code is listed first on a CMS 1500? ›

On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and Page 2 Instructions on how to fill out the CMS 1500 Form telephone number.

What type of claims are submitted on a CMS 1500? ›

The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs.

How many diagnoses can be reported on the CMS 1500? ›

Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim. However, only one diagnosis can be linked to each line item, whether billing on paper or electronically.

What is a HCFA form used for? ›

The HCFA form is what non-institutional practitioners use to bill insurance companies for services provided. The HCFA form comprises medical billing codes and the patient's demographic and insurance information.

What is HCFA in medical billing? ›

Also known as the Healthcare Financing Administration (HCFA) form, the CMS-1500 form is used for claim reimbursem*nt for several government insurance plans such as Medicaid, Tricare, and Medicare. In simple words, this form is used to bill for medical services provided to patients who are covered under insurance.

How do you complete HCFA 1500? ›

How-to Accurately Fill Out the CMS 1500 Form for Faster Payment

How many CPT codes are in a claim? ›

While you can include up to 12 diagnosis codes on a single claim form, only four of those diagnosis codes can map to a specific CPT code.

What goes in box 33 on a HCFA? ›

Description: Box 33 is used to indicate the billing provider's or supplier's billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider's or supplier's billing name, address, ZIP code, and phone number.

What are the two types of claim form? ›

As previously mentioned, there are two types of claims in health insurance, Cashless and Reimbursem*nt Claims.

What is HCFA and UB? ›

The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B. The UB-04 (CMS-1450) to submit charges under Medicare Part A.

What is a UB claim? ›

The UB-04 uniform medical billing form is the standard claim form that any institutional provider can use for the billing of inpatient or outpatient medical and mental health claims. It is a paper claim form printed with red ink on white standard paper.

How do I submit more than 12 diagnosis codes? ›

There is no way to submit more than 12 diagnosis for a single encounter. you cannot have a page 2 for additional diagnosis, the second claim will be rejected as a duplicate. in addition when you do this you are overwriting the "a" diagnosis with a second "a" diagnosis. you can have only 1 "a-L" for a total of 12.

How many blocks are in CMS 1500? ›

The CMS-1500 is divided into 3 blocks and 33 fields/sections. The blocks are—Carrier Block, Patient and Insured Information, and Physician or Supplier Information.

What does POS mean in billing? ›

Key Takeaways

A point of sale (POS) is a place where a customer executes the payment for goods or services and where sales taxes may become payable. A POS transaction may occur in person or online, with receipts generated either in print or electronically.

What is a HCFA 1500 and UB 92 form? ›

HCFA 1450, Uniform/Universal Billing form 92 Managed care The official HCFA/CMS form used by hospitals and health care centers when submitting bills to Medicare and 3rd-party payors for reimbursem*nt for health services provided to Pts covered. See Compliance. Cf HCFA 1500.

Why is medical billing important? ›

Medical coders need to be able to analyze the information in the patients' records in order to determine what codes are appropriate. This is important so that the billing is accurate and the healthcare service provider gets paid on time for the services rendered.

What are the 10 steps in the medical billing process? ›

The ten steps in the process of Medical billing are as follows:
  1. Patient registration.
  2. Insurance verification.
  3. Encounter.
  4. Medical transcription.
  5. Medical coding.
  6. Charge entry.
  7. Charge transmission.
  8. AR calling.
Jan 29, 2020

What are the two types of forms used for health services billing? ›

The Two Types of Medical Billing and Coding
  • Professional billing is completed on the CMS-1500 Forms.
  • Medicare, Medicaid, and some other companies will accept electronic filing of claims (primary form of filing), but some are still made via paper.
Jul 9, 2020

What is a clean claim in medical billing? ›

1. Clean claim defined: A clean claim has no defect, impropriety or special circ*mstance, including incomplete documentation that delays timely payment.

Where is the claim number on a HCFA? ›

The number in Box 26 is your claim number. I. Box 27 of this form is called the assignment indicator.

What is a final step in processing CMS 1500 claims? ›

A final step in processing a CMS-1500 claims is to: Double-check claims for errors and omissions.

Who maintains CPT? ›

The CPT® Editorial Panel is responsible for maintaining the CPT code set. The Panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines.

What is ICD-10-PCS used for? ›

ICD-10-PCS will be the official system of assigning codes to procedures associated with hospital utilization in the United States. ICD-10-PCS codes will support data collection, payment and electronic health records. ICD-10-PCS is a medical classification coding system for procedural codes.

Is HCPCS the same as CPT? ›

1. CPT is a code set to describe medical, surgical ,and diagnostic services; HCPCS are codes based on the CPT to provide standardized coding when healthcare is delivered.

What is Box 24h on HCFA 1500? ›

Box 24h - EPSDT Reason Codes

Available – Not Used (Patient refused referral.) Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.)

What is Box 24c on HCFA? ›

Box 24c. EMG indicator (also called emergency indicator) is a carryover from the older CMS-1500 form and is unlikely to be required on current claims. If needed, however, you can add the 'EMG' field via the service line Column Chooser. Acceptable values are Y or N.

What is Box 31 on a HCFA? ›

Enter the rendering provider's name and date. − Provider should be registered with AHCCCS under the NPI submitted in 24J. − May be an individual provider or the group agency.

Who process the claims? ›

Claims processing begins when a healthcare provider has submitted a claim request to the insurance company. Sometimes, claim requests are directly submitted by medical billers in the healthcare facility and sometimes, it is done through a clearing house.

What is claim cycle? ›

Claims Management runs a scheduled integration that pulls invoiced orders from Front Office and converts each invoice into a claim that appears in Claims Management. When a claim first appears in Claims Management, review the claim and edit it if necessary.

What is TPA ID NO? ›

The TPA offers the ID card and a Unique Identification Number to the patient, which helps in claim settlement. Thus, the TPA is the link between the insurance company and the policyholder when it comes to availing the hospitalisation cover and processing claims.

Who fills out HCFA 1500 form? ›

The HCFA-1500 (CMS 1500) is a medical claim form employed by doctors, nurses, and professionals, including chiropractors and therapists to process the medical claim of a patient.

How do I print HCFA forms? ›

How to print your CMS 1500 form
  1. Select Download complete form if you want to generate the full, red CMS 1500 form as a PDF.
  2. Select Download field entries only if you want to only generate the data fields so you can print it onto a blank CMS 1500 form.
Jan 24, 2022

What is UB modifier? ›

UB Used for surgical or general anesthesia-related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code.

What is UB-04 claim? ›

The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Adult Day Health Care).

What is Box 17 on a UB04? ›

Policy: Field Locator 17 of the UB-04 and its electronic equivalence is a required field on all institutional claims. This code indicates the disposition or discharge status of the beneficiary on the submitted claims.

Is there a new CMS 1500 form? ›

The NUCC has recently changed the Form CMS-1500, and the revised form received OMB approval on June 10, 2013. The revised form is version 02/12, OMB control number 0938-1197. The revised form will replace the previous version of the form 08/05, OMB control number 0938-0999.

Is HCFA 1500 and CMS 1500 the same? ›

The HCFA 1500 claim form, also known as CMS-1500, enables medical physicians to submit health insurance claims for reimbursem*nt from various government insurance plans including Medicare, Medicaid and Tricare.

Why was CMS 1500 changed? ›

Goals of the Revised CMS-1500

To increase provider participation in WC as it is easier to use than the forms it will be replacing, mainly because it relies heavily on the attached medical narrative (providers have commented the current forms are too time consuming).

What is a ub92 claim form? ›

Form UB 92 is also known as a Uniform or Universal Billing form. It is used in the healthcare industry to submit insurance claims to Medicare or other health insurance companies. Completion of this form helps insurance companies decide whether the healthcare provider should receive reimbursem*nt.

What are the two types of claim form? ›

As previously mentioned, there are two types of claims in health insurance, Cashless and Reimbursem*nt Claims.

What goes in box 33 on a HCFA? ›

Description: Box 33 is used to indicate the billing provider's or supplier's billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider's or supplier's billing name, address, ZIP code, and phone number.

How many blocks are in CMS-1500? ›

The CMS-1500 is divided into 3 blocks and 33 fields/sections. The blocks are—Carrier Block, Patient and Insured Information, and Physician or Supplier Information.

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