CMS-1500 Claim Form Completion for Ambulance Providers
IMPORTANT INFORMATION FOR CMS-1500 CLAIM FORM COMPLETION
Note #1: If you are submitting handwritten claimforms you must use blue or black ink.
Note #2: Font Sizes— Because of limited field size, either of the following type faces and sizes are recommended for form completion:
• Times New Roman, 10point
• Arial, 10 Point
Other fonts may be used, but ensure that all data will fit into the fields, or the claim may not process correctly.
Note #3: When completing the following blocks of the CMS-1500,do not use decimal points and be sure to enter dollars and cents:
1 .Block 24F ($Charges)
2. Block 29 (Amount Paid)
If you fail to enter both dollars and cents, your claim may process incorrectly. Forexample, if your usual charge is sixty-five dollars and you enter 65, your usual chargemay be read as .65 cents.
When completing Block 24F, enter your usual charge to the general public, without a decimal point. You must include the dollars and cents. If your usual charge is two hundred and fifty dollars, enter:
When completing Block 29, you are reporting patient pay assigned by the CountyAssistance Office (CAO). Enter patient payas follows, including dollars and cents: