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 Mississippi.

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CMS-1500 (HCFA)

Applicable Services

Filling out the Form


Required Reports

Forms & Attachments

Timely Filing

20 days from DOS

CMS-1500 (HCFA) Services

The following table provides a link to the Mississippi rules which require a provider to use the CMS-1500 (HCFA) for billing purposes. The rules do not specifically mention any services in particular; the following are suggested based on common practice.



Physician Services

Title 20: Labor Part 1: Rules of the Mississippi Workers’ Compensation Commission; Rule 1.9 Selection of Medical.

Laboratory / Pathology


Dispensed Pharmaceuticals

CMS-1500 Form Instructions

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

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, Mississippi requires the provider to submit the following supporting documentation with the CMS-1500 Form, when applicable.

CMS-1500 Medical Bill

Required Documents


Initial office visit notes which document a history, physical examination, assessment and plan appropriate to the level of service indicated by the presenting injury/illness or treatment of the ongoing injury/illness.

Progress notes which reflect patient complaints, objective findings, assessment of the problem, and plan of care or treatment.


Operative reports, consultation notes with report, and/or dictated report.


Copies of lab, x-ray, or other diagnostic tests that reflect current progress of the patient and/or response to therapy or treatment


Copies of lab, x-ray, or other diagnostic tests that reflect current progress of the patient and/or response to therapy or treatment


Physical medicine/occupational therapy progress notes that reflect the patient’s response to treatment/therapy.

A progress report every thirty (30) days for therapy

services/treatment (P.T., O.T., C.M.T., O.M.T.);


The anesthesia record for anesthesia services;


A functional capacity or work hardening evaluation;

By Report

When billing “By Report” (BR), a description of the service is required; this description should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service;

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

Timely Filing

Medical Bill’s must be filed within 20 days of the date of service for services rendered in Mississippi.


Timely Filing

General & Procedural Rules of the Commission

Mississippi Workers’ Compensation Commission Rule

Medical Bills

20 days from DOI

Laws and Claims General & Procedural Rules Of the Commission

Title 20: Part 1: Rule 1.9 Selection of Medical (PDF)

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