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

CMS-1500 Form Instructions

In Title 40; Chapter 51; Section 5111, the Louisiana Administrative Code requires providers to use the CMS-1500 (HCFA) to bill for all professional services to include the following:

1. provide the claimant's full name and address;
2. indicate the Social Security number; this cuts down on errors and helps correlate the billing to the appropriate file;
3. identify correct date of injury, if possible;
4. complete name and address of the employer, not just an individual's name;
5. name of the insurance carrier;
6. the attending physician should indicate the date the claimant's disability should begin;
7. the attending physician should list all diagnoses and claimant's complaints;
8. the date of the visit, the service(s) or procedure(s) performed and charges;
9. provider's complete name and address;
10. provider's identification number, i.e., tax identification number (TIN) or Social Security number.

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. This information is provided 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, Louisiana 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 Louisiana Billing Guide.

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