In Arizona, healthcare providers use the CMS-1500 (HCFA) Form to file original workers' compensation medical bills.
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Filling out the Form |
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Supporting Documentation |
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Timely Filing |
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:
- Identify the patient
- Support the diagnosis
- Justify the treatment
- Accurately document the results
- Indicate advice and cautionary warnings provided to the patient
- 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 |
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