The CMS-1500 (HCFA) Form is used by healthcare providers and professionals to file original workers’ compensation bills in Arizona.
CMS-1500 (HCFA) Form Instructions
Arizona has limited guidance on completing the CMS-1500 Form.
To make things easier for providers, daisyBill created this NUCC CMS-1500 Instructions Table showing the requirements of the National Uniform Claim Committee (NUCC), the entity that created and maintains the form. This information is for educational purposes only and is not intended to represent state-specific requirements.
For additional information, review the complete NUCC Manual:
1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12
CMS-1500 Required Billing Documentation
For a complete bill, Arizona requires the provider to submit the following supporting documentation with the CMS-1500 Form, when applicable.
CMS-1500 Medical Bill |
Required Documents |
Physician’s Services |
Adequate Medical Reports |
E/M 4th or 5th Level |
Narrative Report Justifying E/M Level |
DME |
Invoices showing actual costs |
Radiology |
X-ray findings and the attending physician’s written order |
Laboratory |
Point of Care Drug Testing Documentation |
PT/OT |
Modality or Therapeutic Procedure Justification |
Additional Bill Requirements
Arizona Revised Statutes § 23-1062.01 - Timely payment of medical, surgical and hospital benefit billing; content of bills; contracts between providers and carriers; exceptions; definitions
B. Any billing by a health care provider shall include all of the following:
1. The correct demographic patient information and claim number, if known.
2. The correct health care provider information, including name, address, telephone number and federal taxpayer identification number.
3. The appropriate medical coding with dollar amounts and units clearly stated with all descriptions.
4. Clearly printed date or dates of service.
5. Legible medical reports required for each date of service if the billing is for direct treatment of the injured worker.
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