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Bill Instructions: CMS-1500 (HCFA)

In Arizona, healthcare providers use the CMS-1500 (HCFA) Form to file original workers' compensation medical bills.

Article Contents

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Filling out the Form

Instructions

Supporting Documentation

Forms & Attachments

Timely Filing

24 months from DOS

CMS-1500 (HCFA) Form Instructions

Per 23-1062.01. B of Arizona’s Revised Statutes on Labor, the state requires providers to submit a bill, but they have very limited requirements. These requirements are covered by using the CMS-1500 Form. The state has also indicated that most payers in the state do accept 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

CMS-1500 Required Billing Documentation

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

CMS-1500 Medical Bill

Required Documents

Physician’s Services

Adequate Medical Reports

E/M 4th or 5th Level

Narrative Report Justifying E/M Level

DME

Invoices showing actual costs

Radiology

X-ray findings and attending physician’s written order

Laboratory

Point of Care Drug Testing Documentation

PT/OT

Modality or Therapeutic Procedure Justification

"Adequate records" means legible medical records, produced by hand or electronically, which:

  1. Identify the patient
  2. Support the diagnosis
  3. Justify the treatment
  4. Accurately document the results
  5. Indicate advice and cautionary warnings provided to the patient
  6. Provide sufficient information for another practitioner to assume continuity of the patient's care at any point in the course of treatment

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

Timely Filing

Medical Bills must be filed within 24 months of the date of service for all services rendered in Arizona.

Form

Timely Filing

Administrative Code

Rule

Medical Bill

24 months

ARS Title 23 Chapter 6 Workers' Compensation

Rule 23-1062.01. C

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