The CMS-1500 (HCFA) Form is used by healthcare providers and professionals to file original workers' compensation medical bills in Texas.
Article Contents |
Navigation Link |
Reporting Requirements |
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Timely Filing |
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Filling out the Form |
CMS-1500 Required Supporting Documents
For a complete bill, Texas requires healthcare providers to submit the following supporting documentation with the CMS-1500 Form when applicable.
CMS-1500 Medical Bill |
Required Supporting Documentation |
E / M |
The two highest Evaluation and Management office visit codes for new and established patients: office visit notes/report satisfying the American Medical Association requirements for use of those CPT codes. |
Surgery |
Surgical services rendered on the same date for which the total of the fees established in the current Division fee guideline exceeds $500: a copy of the operative report. |
Return to Work |
Return to work rehabilitation programs as defined in §134.202 of this title (relating to Medical Fee Guideline): a copy of progress notes and/or SOAP (subjective/objective assessment plan/procedure) notes, which substantiate the care given, and indicate progress, improvement, the date of the next treatment(s) and/or service(s), complications, and expected release dates. |
Codes with no MAR |
Any supporting documentation for procedures which do not have an established Division maximum allowable reimbursement (MAR), to include an exact description of the health care provided. |
For additional information related to reporting please refer to daisyBill’s Texas Billing Guide.
Timely Filing
Medical bills must be filed within 95 days of the date of service for all services rendered in Texas.
Form |
Timely Filing |
Texas Administrative Code |
Rule |
Medical Bills |
95 days |
CMS-1500 (HCFA) Instructions
The Texas Administrative Code Rule §133.10 requires health care providers to use the CMS-1500 (HCFA) for billing purposes. To file a complete professional or noninstitutional medical bill, the CMS-1500 Form must be filled out as detailed in the following tables.
For additional general information on the CMS-1500, review the complete NUCC Manual:
1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12
Items 0 through 10
CMS-1500 Box # |
CMS-1500 (02/12) Field Description |
Texas Workers' Compensation Requirements (Required / Situational / Optional / Not Applicable) |
Texas Workers' Compensation Instructions |
0 |
CARRIER NAME AND ADDRESS |
||
1 |
MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA, BLACK LUNG, OTHER |
||
1a |
INSURED’S I.D. NUMBER |
R |
Patient's Social Security Number |
2 |
PATIENT’S NAME (Last Name, First Name, Middle Initial) |
R |
Patient's First Name, Last Name, Middle Initial, Name Suffix |
3 |
PATIENT’S BIRTH DATE, SEX |
R |
Patient's Date of Birth and sex |
4 |
INSURED’S NAME (Last Name, First Name, Middle Initial) |
R |
Employer's Name |
5 |
PATIENT’S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE |
R |
Patient's Address, City, State and Zip, Telephone |
6 |
PATIENT RELATIONSHIP TO INSURED |
R |
|
7 |
INSURED'S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE |
R |
|
8 |
RESERVED FOR NUCC USE |
N |
|
9 |
OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) |
N |
|
9a |
OTHER INSURED'S POLICY OR GROUP NUMBER |
No indication |
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9b |
RESERVED FOR NUCC USE |
No indication |
|
9c |
RESERVED FOR NUCC USE |
No indication |
|
9d |
INSURANCE PLAN NAME OR PROGRAM NAME |
No indication |
|
10a |
IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT |
No indication |
|
10b |
IS PATIENT'S CONDITION RELATED TO: AUTO ACCIDENT _ PLACE (State) |
No indication |
|
10c |
IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT |
No indication |
|
10d |
CLAIM CODES (Designated by NUCC) |
No indication |
Top of Section
Items 11 through 20
CMS-1500 Box # |
CMS-1500 (02/12) Field Description |
Texas Workers' Compensation Requirements (Required / Situational / Optional / Not Applicable) |
Texas Workers' Compensation Instructions |
11 |
ISURED'S POLICY GROUP OR FECA NUMBER |
S |
Workers' compensation claim number assigned by the insurance carrier is required when known, the billing provider shall leave the field blank if the workers' compensation claim number is not known by the billing provider |
11a |
INSURED'S DATE OF BIRTH, SEX |
No indication |
|
11b |
OTHER CLAIM ID (Designated by NUCC) |
No indication |
|
11c |
INSURANCE PLAN NAME OR PROGRAM NAME |
No indication |
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11d |
IS THERE ANOTHER HEALTH BENEFIT PLAN? |
No indication |
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12 |
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE |
No indication |
|
13 |
INSURED'S OR AUTHORIZED PERSONS' SIGNATURE |
No indication |
|
14 |
DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP) |
R |
Date of injury and "431" qualifier are required |
15 |
OTHER DATE |
No indication |
|
16 |
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION |
No indication |
|
17 |
NAME OF REFERRING PROVIDER OR OTHER SOURCE |
Name of referring provider or other source is required when another health care provider referred the patient for the services; No qualifier indicating the role of the provider is required |
|
17a |
OTHER ID # |
S |
Referring provider's state license number is required when there is a referring doctor listed in CMS-1500/field 17; the billing provider shall enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX') |
17b |
NPI # |
S |
Referring provider's National Provider Identifier (NPI) number is required when CMS-1500/field 17 contains the name of a health care provider eligible to receive an NPI number |
18 |
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES |
No indication |
|
19 |
ADDITIONAL CLAIM INFORMATION (Designated by NUCC) |
No indication |
|
20 |
OUTSIDE LAB? |
No indication |
Top of Section
Items 21 through 33
CMS-1500 Box # |
CMS-1500 (02/12) Field Description |
Texas Workers' Compensation Requirements (Required / Situational / Optional / Not Applicable) |
Texas Workers' Compensation Instructions |
21 |
ICD IND. |
R |
|
21.A |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.B |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
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21.C |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
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21.D |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
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21.E |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.F |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.G |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.H |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.I |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.J |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.K |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
21.L |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
S |
|
22 |
RESUBMISSION CODE |
No indication |
|
23 |
PRIOR AUTHORIZATION NUMBER |
S |
Prior authorization number is required when preauthorization, concurrent review or voluntary certification was approved and the insurance carrier provided an approval number to the requesting health care provider |
24A |
DATE(S) OF SERVICE |
R |
|
24B |
PLACE OF SERVICE |
R |
|
24C |
EMG |
R |
|
24D |
PROCEDURES, SERVICES, OR SUPPLIES |
R |
|
24E |
DIAGNOSIS CODE POINTER |
R |
|
24F |
$ CHARGES |
R |
|
24G |
DAYS OR UNITS |
R |
|
24H |
EPSDT/FAMILY PLAN |
No indication |
|
24I Grey |
ID QUAL |
No indication |
|
24J Grey |
RENDERING PROVIDER ID. # |
S |
Rendering provider's state license number is required when the rendering provider is not the billing provider listed in CMS-1500/field 33; the billing provider shall enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX') |
24J |
NPI# |
S |
Rendering provider's NPI number is required when the rendering provider is not the billing provider listed in CMS-1500/field 33 and the rendering provider is eligible for an NPI number |
24 Grey |
GREY AREA SUPPLEMENTAL DATA |
S |
Supplemental information is required when the provider is requesting separate reimbursement for surgically implanted devices or when additional information is necessary to adjudicate payment for the related service line |
25 |
FEDERAL TAX ID. NUMBER |
R |
|
26 |
PATIENT'S ACCOUNT NO. |
No indication |
|
27 |
ACCEPT ASSIGNMENT? |
No indication |
|
28 |
TOTAL CHARGE |
R |
|
29 |
AMOUNT PAID |
No indication |
|
30 |
RSVD FOR NUCC USE |
No indication |
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31 |
SIGNATURE OF PHYSICIAN OR SUPPLIER |
R |
Signature of physician or supplier, the degrees or credentials, and the date is required, but the signature may be represented with a notation that the signature is on file and the typed name of the physician or supplier |
32 |
SERVICE FACILITY LOCATION INFORMATION |
R |
|
32a |
NPI # |
S |
Service facility NPI number is required when the facility is eligible for an NPI number |
32b |
OTHER ID # |
No indication |
|
33 |
BILLING PROVIDER INFO & PH # |
R |
|
33a |
NPI # |
S |
Billing provider's NPI number is required when the billing provider is eligible for an NPI number |
33b |
OTHER ID # |
S |
Billing provider's state license number is required when the billing provider has a state license number; the billing provider shall enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX') |
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