EdexCloud CMS1500

Coversheet Version 1.1 MANDATORY!

Insurance Plan Type*

Insured's ID Number**

Patient condition related to* :

Employment

Other Accident

Auto Accident

I would like to submit this claim Electronically.

Claim Filing Indicator

Delay Reason

Payer Responsibility*

Employer MANDATORY!

Employer Name*

Address Profile

Address Line*

City* / State* / Zip Code* / Phone Number*

Illness Mandatory

Current Illness, Injury, or Pregnancy (LMP)*

Current Illness Date*

Unable to Work

Date From

Date To

Hospitalization

Date From

Date To

Laboratory

Outside

Charges : $

Referring Provider

FirstName / LastName

Provider Type

Referring

Ordering

Supervising

NPI

UPIN

State License Number

Commercial Number

Location Number

Rendering Provider Mandatory

FirstName* / LastName*

NPI*

Taxomony Code

Signature*

Signature Date*

Billing Provider Mandatory

Billing Provider Name*

Address*

City*/State*/Zip Code*

NPI*

Taxomony Code

EIN

License No.

Tax ID*

TaxID For*

SSN

EIN

Contact Person

Phone*

Diagnosis Codes Mandatory

Diagnosis or nature of illness or injury

Service Facility Mandatory

Facility Name*

NPI*

Phone*

Address*

City* / State* / Zip Code*

Services Rendered - Procedure Code(s) Mandatory

Date of Service* CPT* Modifier(s) ICD(s)* Fee(s)* Unit(s)* NPI*

Amount Paid: $

Insurance Carrier

This section is required when claim requires electronic submission.

Insurance Carrier Name*

Payer ID*

Address Profile

Address Line*

City* / State* / Zip Code*

HCFA
CMS1500

HEALTH INSURANCE CLAIM FORM

Draft

Coversheet Version 1.1 MANDATORY!

Injured Worker MANDATORY!

Address Profile

Insured

Address Profile

Other Insured

Signature

Employer MANDATORY!

Address Profile

Illness Mandatory

Current Illness, Injury, or Pregnancy (LMP)*

Unable to Work

Hospitalization

Laboratory

Referring Provider

Rendering Provider Mandatory

Billing Provider Mandatory

Diagnosis Codes Mandatory

Diagnosis or nature of illness or injury

Service Facility Mandatory

Services Rendered - Procedure Code(s) Mandatory

Insurance Carrier

This section is required when claim requires electronic submission.

Address Profile

HCFA 1500 Claim Form

ANSI ASC X12N 837 - Health Care Claim (837) transaction

Submitter

Receiver

ANSI ASC X12N 837 JSON - Health Care Claim (837) transaction

HCFACMS1500

HEALTH INSURANCE CLAIM FORM

Draft

Address Profile

Address Profile

Address Profile

Current Illness, Injury, or Pregnancy (LMP)*

Unable to Work

Hospitalization

Laboratory

Diagnosis or nature of illness or injury

This section is required when claim requires electronic submission.

Address Profile

HCFA 1500 Claim Form

ANSI ASC X12N 837 - Health Care Claim (837) transaction

Submitter

Receiver

ANSI ASC X12N 837 JSON - Health Care Claim (837) transaction

HCFA
CMS1500