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In State Form

This document is a health insurance claim form containing information about a patient, their insurance plan, and medical services received. Key details include: - The patient's name, birthdate, address, and relationship to the insured individual. - The insurance plan is listed as the New York State Government Employees Health Insurance Program with the Empire Plan. - Sections are included to provide diagnosis codes, procedures performed, dates of service, charges, and billing information.

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cobra1100
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© Attribution Non-Commercial (BY-NC)
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41 views

In State Form

This document is a health insurance claim form containing information about a patient, their insurance plan, and medical services received. Key details include: - The patient's name, birthdate, address, and relationship to the insured individual. - The insurance plan is listed as the New York State Government Employees Health Insurance Program with the Empire Plan. - Sections are included to provide diagnosis codes, procedures performed, dates of service, charges, and billing information.

Uploaded by

cobra1100
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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1500

New York State Government Employees Health Insurance Program


PICA 1. MEDICARE
(Medicare #)

HEALTH INSURANCE CLAIM FORM


APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 GROUP HEALTH PLAN FECA BLK LUNG
(SSN) Y

MEDICAID
(Medicaid #)

TRICARE CHAMPUS
(Sponsors SSN)

CHAMPVA
(Memberchip ID#)

OTHER
(ID)

1a. INSUREDS I.D. NUMBER

PICA (For Program In Item 1)

(SSN or ID) MM DD

2. PATIENTS NAME (Last Name, First Name, Middle Initial)

3. PATIENTS BIRTH DATE M

SEX F

4. INSUREDS NAME (Last Name, First Name, Middle Initial)

5. PATIENTS ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED


Self Spouse Child Other

7. INSUREDS ADDRESS (No., Street)

CITY

STATE

8. PATIENT STATUS
Single Married Other

CITY

STATE

ZIP CODE

TELEPHONE (Include Area Code)

ZIP CODE
Employed Full-Time Student Part-Time Student

TELEPHONE (Include Area Code)

( 30500
a. INSUREDS DATE OF BIRTH
MM DD YY

9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial)

10. IS PATIENTS CONDITION RELATED TO:

11. INSUREDS POLICY GROUP OR FECA NUMBER

a. OTHER INSUREDS POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous) YES NO

SEX M F

b. OTHER INSUREDS BIRTH DATE


MM DD YY

SEX M F

b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES

PLACE (State) b. EMPLOYERS NAME OR SCHOOL NAME NO c. INSURANCE PLAN NAME OR PROGRAM NAME NO

c. EMPLOYERS NAME OR SCHOOL NAME

EMPIRE PLAN
YES NO

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR MM DD YY INJURY(Accident) OR PREGNANCY (LMP) 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE DATE 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. MM DD YY GIVE FIRST DATE 17a. 17b. 19. RESERVED FOR LOCAL USE NPI

13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION.


MM DD YY MM DD YY

FROM
MM DD YY

TO
MM DD YY

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES. FROM 20. OUTSIDE LAB? YES NO ORIGINAL REF. NO. TO $ CHARGES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE) 1. 2. 24. A DATE(S) OF SERVICE From To
MM DD YY MM DD YY

22. MEDICAID RESUBMISSION CODE

. .
B
Place of Service

3. 4. C
EMG

. .
E DIAGNOSIS POINTER

23. PRIOR AUTHORIZATION NUMBER

D PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

F $ CHARGES

G
DAYS OR UNITS

H
EPSDT Family Plan

I
ID QUAL

J RENDERING PROVIDER ID. #

NPI NPI

2 NPI 3 NPI 4 NPI 5 NPI 6 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT N0. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)

28. TOTAL CHARGE $

29. AMOUNT PAID $ (

30. BALANCE DUE $ )

YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY INFORMATION

NO

33. BILLING PROVIDER INFO & PH #

SIGNED

DATE

a.

NPI

b.

a.

NPI

b.

NUCC Instruction Manual available at: www.nucc.org

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

PHYSICIAN OR SUPPLIER INFORMATION

PATIENT AND INSURED INFORMATION

CARRIER

INSURANCE FRAUDS PREVENTION ACT The following statement is printed pursuant to Regulation 95 of the New York State Insurance Department: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PLEASE MAIL CLAIMS TO: United HealthCare Insurance Company of New York P.O. Box 1600 Kingston, New York 12402-1600 1-877-7NYSHIP (1-877-769-7447)

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