The CMS-1500 (HCFA) Form is used by healthcare providers and professionals to file original workers' compensation medical bills in Maryland.

CMS-1500 (HCFA) Services

The following table provides a link to the Maryland regulations which require non-institutional providers to use the CMS-1500 (HCFA) for billing purposes.

CMS-1500 Form Instructions

The state of Maryland requires providers to compliantly complete the CMS-1500 Form to include the following:

1. An itemized list of each service;
2. The diagnosis relative to each service;
3. The medical records related to the service being billed;
4. The appropriate CPT/HCPCS code with CPT modifiers, if any, for each service;
5. The date of each service;
6. The specific fee charged for each service;
7. The tax ID number of the provider;
8. The professional license number of the provider; and
9. The National Provider Identifier (NPI) of the provider.

To make things easier for you, daisyBill created this NUCC CMS-1500 Instructions Table showing the requirements of the National Uniform Claim Committee (NUCC), the entity which created and maintains the form. All Maryland-specific requirements are met if the standard NUCC requirements are followed.

For additional information, review the complete NUCC Manual:
1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12

CMS-1500 Required Documentation

For a complete bill, Arizona requires the provider to submit the following supporting documentation with the CMS-1500 Form, when applicable.

For additional information related to reporting please refer to daisyBill’s Maryland Billing Guide.

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