CMS-1500 Form

Which of the following services would be expected to be reported on a CMS-1500 claim form?

• Room and board

• Physician office visits and surgical procedures

• Inpatient Services

• Supplies for local anesthesia

What does it mean for a provider to accept assignment?

• To accept the patients assigned to the office as new patients

• To accept the negotiated rate as the full rate for the service

• To accept payment in full from the patient

• To accept responsibility for the assignment of the diagnostic and procedure codes

By printing "Signature on File" in the item 13 of the CMS-1500 claim form, what is the provider stating?

• The provider has a form signed by the patient authorizing payment of medical benefits directly to the provider

• The provider has a form signed by the patient authorizing release of medical records to relatives

• The provider has a signature ledger on file for the patient

• The provider's signature log is attached to the claim

What type of services are reported on a UB-04 form?

• Physician services

• Non-physician practitioner services

• Surgeries performed at ambulatory surgical center (ASCs)

• Hospital facility services

What is the CMS 1500 Claim Form?

• Standard form for paper claims
• Standard form for electronic claims
• Standard form for creating virtual fedoras
• Standard form for submitting math tests

Which of these is a CMS 1500 form?

• 
• 
• 
• 

Hard-copy professional claims, generally submitted by physicians are on which type of form:

• UB-04

• CMS 1500

• HMSA 1500

• HMSA 04

Hard-copy institutional claims, generally submitted by hospitals are on which type of form:

• UB-04

• CMS 1500

• HMSA 1500

• HMSA 04

What information is located in block 21 of the CMS-1500 form?

• Diagnosis

• CPT Codes

• ICD-10-CM

• Provider NPI

• SOF

What is entered in block 1a. of the CMS-1500 form?

• Insured's ID number

• Patient name

• Patient address

• Insured's name