The CMS-1500 (HCFA) Form is used by healthcare providers and professionals to file original workers' compensation medical bills in Washington.
Article Contents |
Navigation Link |
CMS-1500 (HCFA) |
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Reporting Requirements |
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Timely Filing |
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Filling out the Form |
CMS-1500 (HCFA) Services
The following table provides a link to the Washington Billing Procedures which require a provider to use the CMS-1500 (HCFA) for billing purposes.
Service |
Procedure |
Physicians |
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Osteopaths | |
Advanced Registered Nurse Practitioners | |
Chiropractors | |
Naturopaths | |
Podiatrists | |
Psychologists | |
Registered Physical Therapists |
CMS-1500 Required Documentation
For a complete bill, Washington requires the provider to submit the following supporting documentation with the CMS-1500 Form, when applicable.
CMS-1500 Medical Bill |
Required Documents |
Treatment |
Attach Chart Notes |
Surgery |
Operative Report |
Radiology |
Radiology Report if billing for Professional Component |
Laboratory |
Test Results Report |
Diagnostic Testing |
Test Results Report |
For more information related to reporting please refer to daisyBill’s Washington Billing Guide.
Timely Filing
Medical Bills must be filed within 12 months of the date of service for all services rendered in Washington.
Form |
Timely Filing |
Washington State Dept of Labor & Industry |
Rule |
Medical Bills |
12 months |
CMS-1500 Form Instructions
The state of Washington requires providers to compliantly complete the CMS-1500 form as detailed in the following tables.
For additional information, 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 |
Washington Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable) |
Washington Workers' Compensation Instructions |
0 |
CARRIER NAME AND ADDRESS |
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1 |
MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA, BLACK LUNG, OTHER |
N |
|
1a |
INSURED’S I.D. NUMBER |
R |
Worker's social security number or Claim Number can be accepted in this box |
2 |
PATIENT’S NAME (Last Name, First Name, Middle Initial) |
R |
Worker's legal name in last, first, middle initial format |
3 |
PATIENT’S BIRTH DATE, SEX |
R |
Worker's date of birth |
4 |
INSURED’S NAME (Last Name, First Name, Middle Initial) |
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5 |
PATIENT’S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE |
R |
Worker's current address |
6 |
PATIENT RELATIONSHIP TO INSURED |
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7 |
INSURED'S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE |
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8 |
RESERVED FOR NUCC USE |
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9 |
OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) |
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9a |
OTHER INSURED'S POLICY OR GROUP NUMBER |
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9b |
RESERVED FOR NUCC USE |
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9c |
RESERVED FOR NUCC USE |
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9d |
INSURANCE PLAN NAME OR PROGRAM NAME |
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10a |
IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT |
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10b |
IS PATIENT'S CONDITION RELATED TO: AUTO ACCIDENT _ PLACE (State) |
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10c |
IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT |
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10d |
CLAIM CODES (Designated by NUCC) |
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Items 11 through 20
CMS 1500 Box # |
CMS 1500 (02/12) Field Description |
Washington Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable) |
Washington Workers' Compensation Instructions |
11 |
INSURED'S POLICY GROUP OR FECA NUMBER |
R |
L&I claim(s) number |
11a |
INSURED'S DATE OF BIRTH, SEX |
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11b |
OTHER CLAIM ID (Designated by NUCC) |
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11c |
INSURANCE PLAN NAME OR PROGRAM NAME |
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11d |
IS THERE ANOTHER HEALTH BENEFIT PLAN? |
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12 |
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE |
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13 |
INSURED'S OR AUTHORIZED PERSONS' SIGNATURE |
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14 |
DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP) |
R |
Date of injury |
15 |
OTHER DATE |
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16 |
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION |
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17 |
NAME OF REFERRING PROVIDER OR OTHER SOURCE |
S |
Referring provider, if applicable |
17a |
OTHER ID # |
S |
L&I provider number of referring provider, if applicable |
17b |
NPI # |
S |
NPI of referring provider, if applicable |
18 |
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES |
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19 |
ADDITIONAL CLAIM INFORMATION (Designated by NUCC) |
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20 |
OUTSIDE LAB? |
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Items 21 through 33
CMS 1500 Box # |
CMS 1500 (02/12) Field Description |
Washington Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable) |
Washington Workers' Compensation Instructions |
21 |
ICD IND. |
R |
Diagnosis code (ICD-9 or ICD-10 code) |
21.A |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.B |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.C |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.D |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.E |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.F |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.G |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.H |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.I |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.J |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.K |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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21.L |
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E) |
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22 |
RESUBMISSION CODE |
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23 |
PRIOR AUTHORIZATION NUMBER |
S |
L&I prior authorization number |
24A |
DATE(S) OF SERVICE |
R |
Date(s) of service |
24B |
PLACE OF SERVICE |
R |
Enter and L&I place of service |
24C |
EMG |
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24D |
PROCEDURES, SERVICES, OR SUPPLIES |
R |
Procedure performed (ICD code, HCPCS, or Local Code) |
24E |
DIAGNOSIS CODE POINTER |
R |
Diagnosis code (ICD-9 or ICD-10 code) |
24F |
$ CHARGES |
R |
Your usual & customary fee |
24G |
DAYS OR UNITS |
R |
Total number of units, minutes, or days |
24H |
EPSDT/FAMILY PLAN |
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24I Grey |
ID QUAL |
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24J Grey |
RENDERING PROVIDER ID. # |
R |
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24J |
NPI# |
N |
L&I provider number or L&I registered NPI |
24 Grey |
GREY AREA SUPPLEMENTAL DATA |
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25 |
FEDERAL TAX ID. NUMBER |
R |
Federal Tax ID Number |
26 |
PATIENT'S ACCOUNT NO. |
R |
The number you use to identify the patient account |
27 |
ACCEPT ASSIGNMENT? |
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28 |
TOTAL CHARGE |
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29 |
AMOUNT PAID |
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30 |
RSVD FOR NUCC USE |
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31 |
SIGNATURE OF PHYSICIAN OR SUPPLIER |
R |
Signature of rendering physician |
32 |
SERVICE FACILITY LOCATION INFORMATION |
R |
Facility where treatment was provided |
32a |
NPI # |
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32b |
OTHER ID # |
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33 |
BILLING PROVIDER INFO & PH # |
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33a |
NPI # |
R |
Rendering provider NPI |
33b |
OTHER ID # |
R |
Rendering provider L&I provider number |
If field is blank, it's because L&I has not specified that the field be filled in |
If field is blank, it's because L&I has not specified that the field be filled in |
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