Health Insurance Claim Forms
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1 Health Insurance Claim Forms CMS-1500 for Private Practice UB-04 for Hospitals and Institutions Claim Forms for Dental Offices Compatible Envelopes for easy filing Form Filler Software to automate your claim forms COMPLIANCE CERTIFIED business systems 1325 South Creek Drive, Suite 500, Houston, TX Phone: apex (2739) Fax apex (2739) Website: Shipping locations in Texas, Pennsylvania and California
2 What you need to know about Healthcare Claim Forms... 2 Compliance is critical for medical claim forms... If you file a claim with a form that is not up to date and fully compliant the payer may reject the form, causing a delay in you, the provider, receiving payment. What makes a form compliant or non-compliant? A number of factors... for starters it must adhere to strict printing standards that govern the layout, the paper and the ink. It must also have accurate content like the NPI - the National Provider Identifier and it must conform to the HIPAA - Health Insurance Portability and Accountability Act. How can I be sure that my forms are up-to-date and fully compliant? Two things... first of all, ask us. We can check your current supply of forms. Secondly be sure to order from this catalog. All the forms inthis catalog were developed in conjunction with all the governing agencies including the NUCC - National Uniform Claim Committee, the NUBC - National Uniform Billing Committee, the CMS - Centers for Medicare and Medicaid Services, the HHS - Health and Human Services agency of the US Government and the AHA - American Hospital Association. We are the only provider selected to work exclusively with these agencies in the development of the current forms and are in constant contact with all agencies to be on top of the latest revisions and requirements. Table of Contents Form CMS page 3 For private practice providers and anyone billing within the non-institutional medical industry Form UB-04 - page 4 For hospitals, skilled nursing, home health care facilities and other institutional healthcare providers Attending Dentist s Statements - page 5 All the claim forms officially licensed by the ADA and supported by the most popular dental software packages Compatible Envelopes - page 6 Standard and Jumbo envelopes compatible with the CMS-1500, UB-04 and ADA forms CMS-1500 Form Filler Software - page 7 For private practice providers and anyone billing within the non-institutional medical industry Form UB-04 Form Filler Software - page 8 For hospitals, skilled nursing, home health care facilities and other institutional health care providers
3 CMS-1500 Health Insurance Claim Forms for use by Private Practitioners Accommodates reporting of your NPI - National Provider Identifier. Designed for processing on high speed OCR scanning equipment. Printed in special red dropout ink on basis weight 20# paper. Available for laser, continuous form pin-feed and snap-apart sets. Optional pressure sensitive mailing label available on continuous forms. Label is blown-on, self-imaging. Laser Cut Sheets Item # CMSLC - Single sheet - 2,500 per case Continuous Forms Item # CMS1-1 part form - 2,500 per case Item # CMS2-2 part form - 1,000 per case Paper sequence: White/Canary Item # CMSW2-2 part form - 1,000 per case Paper sequence: White/White Item # CMS3-3 part form - 1,000 per case Paper sequence: White/Canary/Pink Continuous Forms with Labels Item # CMS1B - 1 part form - 1,000 per case Item # CMS2B - 2 part form - 1,000 per case Paper sequence: White/Canary 2-Part Snap-Apart Forms Item # CMSS - 2 part form per case Paper sequence: White/Canary See our Form Filler Software for CMS-1500 on page 7 3
4 UB-04 Health Insurance Claim Forms for Hospitals and Institutions As of March 1, 2007 the UB-04 replaced the UB-92. The form is designed for hospitals to file a medical claim with the patient s insurance carrier. Designed for processing on high speed OCR scanning equipment. Printed in special red dropout ink on basis weight 20# paper. Available for laser and continuous form pin feed with up to five parts. All parts are printed on white carbonless stock. Laser Cut Sheets Item # UB04LC - Single sheet - 2,500 per case Continuous Forms Item # UB041-1 part form - 2,500 per case Item # UB042-2 part form - 2,500 per case Item # UB043-3 part form - 1,000 per case Item # UB044-4 part form per case Item # UB045-5 part form per case See our Form Filler Software for UB-04 on page 8 4
5 Attending Dentist s Statements authorized by the ADA The American Dental Association (ADA) has authorized a number of different claim/attending dentist s forms over the years. We inventory those versions that are supported by the greatest number of dental software packages. We have been officially licensed by the ADA to produce the following versions: 2006, 2004, 2000, 1994, 1990, 1987 and Series Item # Laser-Cut Sheet - 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case 2004 Series Item # Laser-Cut Sheet - 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case 2000 Series Item # Laser-Cut Sheet - 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case Item # 2002S Part Snap-Apart per case 1994 Series Item # Laser-Cut Sheet - 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case Item # 1942S Part Snap-Apart per case 1990 Series Item # Laser-Cut Sheet - 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case 1987 Series Item # Laser-Cut Sheet Item # Part Continuous Item # Part Continuous 2,500 per case 2,500 per case 1,000 per case 1985 Series Item # Laser-Cut Sheet 2,500 per case Item # Part Continuous - 2,500 per case Item # Part Continuous - 1,000 per case Item # B Part Cont. Label - 1,000 per case 5
6 Compatible Claim Form Envelopes CMS-1500, UB-04, ADA Jumbo Envelopes for CMS-1500 and UB-04 Claim Forms As more insurance companies convert to optically scanning your claim forms the need to mail them unfolded becomes increasingly important. When claim forms are folded they may jam the automatic scanning equipment and delay the processing of claims. One way to prevent these delays is to mail claim forms in our jumbo envelope. This 9 x 12-1/2 self-sealing window envelope holds up to 50 unfolded forms. Jumbo envelopes come 500 per case. Item #1500LR - Jumbo Envelope for CMS-1500 with Right Window Item #1500RS - Jumbo Envelope for CMS-1500, Right Window, no wording Item #1492LL - Jumbo Envelope for UB-04 with Left Window CMS-1500 Window Envelopes Our traditional #10-1/2 window envelope holds up to 12 claim forms. It is available with either a gum-seal or self-seal. Three line address on front or back of envelope in black ink is available. 500 per case. Item #1500ES - Self Seal Style Item #1500E - Gum Seal Style Jumbo Envelope ADA Window Envelopes Our ADA window envelope selection offers compatibility with our entire line of Attending Dentist s Statements. 500 per case. Item # 2003ES - Version 2006 & 2004 Item # 2000ES - Version 2000 Item # 1994ES - Versions 1994, 1990, 1987, 1985 Window Envelope 6
7 Speedy Claims Form Filler Software for CMS-1500 Claim Forms Get paid faster with the ultimate in CMS-1500 software - Speedy Claims is what you need to print and file your paper claims quickly and easily to all your insurance payers. Simpler to use than other form filler software Free updates with no add-on costs Free technical support is included Automatic backup of all your data Lower cost than other form filler software Choose CD ROM, Download or Flash Drive Speedy Claims for Paper Claim Filing The ultimate CMS-1500 software... Speedy Claims is what you need to complete and file paper claim forms quickly and easily. Speedy Claims for Electronic Claims All the features of Speedy Claims plus the ability to send your claims electronically. You can print and/or create a file that can be sent to a clearinghouse for electronic filing. Professional Speedy Claims Perfect for Medical Billing Agencies and practices that bill for multiple providers. The software creates a separate database for each provider. For example, when the user selects Dr. Green they see and use his information only. When they switch to Dr. Brown they no longer see Dr. Green s data. For electronic filing only. Paper Version Software (Paper filing only) Item # CMSDL - Speedy Claims Download Item # CMSCD - Speedy Claims CD Disc Item # CMSFD - Speedy Claims Flash Drive Electronic Version (Paper or electronic filing) Item # CMSDLE - Speedy Claims Download Item # CMSCDE - Speedy Claims CD Disc Item # CMSFDE - Speedy Claims Flash Drive Professional Version (Electronic filing only) Available as CD ROM, Download or Flash Drive Item # CMSDLP - Speedy Claims Download Item # CMSCDP - Speedy Claims CD Disc Item # CMSFDP - Speedy Claims Flash Drive 7
8 Speedy Claims Form Filler Software for UB-04 Claim Forms Get paid faster with the ultimate in UB-04 software - Speedy Claims is what you need to print and file your paper claims quickly and easily to all your insurance payers. Simpler to use than other form filler software Free updates with no add-on costs Free technical support is included Automatic backup of all your data Lower cost than other form filler software Choose CD ROM, Download or Flash Drive Speedy Claims for Paper Claim Filing The ultimate UB-04 software... Speedy Claims is what you need to complete and file paper claim forms quickly and easily. Speedy Claims for Electronic Claims All the features of Speedy Claims plus the ability to send your claims electronically. You can print and/or create a file that can be sent to a clearinghouse for electronic filing. Professional Speedy Claims Perfect for Medical Billing Agencies and practices that bill for multiple providers. The software creates a separate database for each provider. For example, when the user selects Dr. Green they see and use his information only. When they switch to Dr. Brown they no longer see Dr. Green s data. For electronic filing only. Paper Version Software (Paper filing only) Item # UBDL - Speedy Claims UB04 - Download Item # UBCD - Speedy Claims UB04 - CD Disc Item # UBFD - Speedy Claims UB04 - Flash Drive Electronic Version (Paper or electronic filing) Item # UBDLE - Speedy Claims UB04 - Download Item # UBCDE - Speedy Claims UB04 - CD Disc Item # UBFDE - Speedy Claims UB04 - Flash Drive Professional Version (Electronic filing only) Item # UBDLP - Speedy ClaimsUB04 - Download Item # UBCDP - Speedy Claims UB04 - CD Disc Item # UBFDP - Speedy Claims UBO4 - Flash Drive Available as CD ROM, Download or Flash Drive 8
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