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Bill Instructions: CMS-1500 (HCFA)

The CMS-1500 (HCFA) Form is used by healthcare providers to file original workers' compensation medical bills for professional services in Utah.

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CMS-1500 (HCFA)

Applicable Services

Filling out the Form

Instructions

Reporting Requirements

Forms & Attachments

Timely Filing

30 days from DOS

CMS-1500 (HCFA) Services

The following table provides a link to the Utah regulations/rules which require a provider to use the CMS-1500 (HCFA) for billing purposes.

Service

Rule

Physician Services

R612-300-7 D. Billing and Payment

Dispensed Pharmaceuticals

Durable Medical Equipment (DME)

CMS-1500 Form Instructions

The state of Utah requires providers to compliantly complete the CMS-1500 Form.

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

For additional information related to reporting please refer to DaisyBill’s Utah Billing Guide.

CMS-1500 Suggested Attachments

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

CMS-1500 Medical Bill

Recommended Attachment

Treatment

Recommend attaching chart notes.

Surgery

Operative Report

Radiology

Radiology Report if billing for Professional Component

Laboratory

Test results report

Diagnostic Testing

Test results report

Timely Filing

CMS-1500 forms must be filed within 30 days of the date of service for all services rendered in Utah.

Form

Timely Filing

Workers’ Compensation Rules

Rule

CMS-1500

30 days

Rule R612-300

D. Billing and Payment.

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