Bill Instructions: CMS-1500 (HCFA)

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

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CMS-1500 (HCFA)

Applicable Services

Filling out the Form


Reporting Requirements

Forms & Attachments

CMS-1500 (HCFA) Services

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



Professional Services

40.021(E) Workers' Compensation Medical Fee Schedule

Laboratory / Pathology

Dispensed Pharmaceuticals

CMS-1500 Form Instructions

The state of Vermont requires providers to compliantly complete the CMS-1500 Form but provides no further specifications.

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 Suggested Billing Documentation

For a complete bill, the Vermont Workers' Compensation Medical Fee Schedule requires providers to “maintain documentation for each service provided which is sufficiently detailed to allow for the review of the medical necessity of the service and the appropriateness of the fee charged.” It is recommended that providers keep the following supporting documentation ready to be submitted upon request when applicable.

CMS-1500 Medical Bill

Recommended  Attachment


Recommend attaching chart notes.


Operative Report


Radiology Report if billing for Professional Component


Test results report

Diagnostic Testing

Test results report

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

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