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Insuredand/orAdministeredbyConnecticutGeneralLifeInsuranceCompanyFailuretoprovidemedicalinformationunderFECAcouldFREECMS(HCFA) CLAIMFORMTEMPLATEPDF:FREECMSTemplateDownload:DOWNLOADFREECMSCLAIMFORMFILLABLETEMPLATE.Thisformcanbe usedwithallmedicalplansItisthebasicpaperclaimformprescribedbymanyhealthplansforclaimssubmittedbyInstructionsforCompletingOWCPHealth InsuranceClaimFormForMedicalServicesProvidedUndertheFEDERALEMPLOYEES'COMPENSATIONACT(FECA),theBLACKLUNG BENEFITSACT(BLBA),andtheENERGYEMPLOYEESOCCUPATIONALILLNESSINSURED’SIDNUMBER(ForPrograminItem
1)INSURED’SNAME(LastName,FirstName,MiddleInitial)INSURED’SADDRESS(No,Street)CITYSTATEZIPCODETELEPHONE(IncludeArea Code)INSURED’SPOLICYGROUPORFECANUMBERaINSURED’SDATEOFBIRTHSEXMMDDYYMFbINSURANCEPLANNAME Professionalpaperclaimform(CMS)TheCMSformisthestandardclaimformusedbyanon-institutionalproviderorsuppliertobillMedicarecarriersand durablemedicalequipmentregionalcarriers(DMERCs)whenaproviderqualifiesforawaiverfromtheAdministrativeSimplificationComplianceAct(ASCA) requirementforelectronicTheHealthInsuranceClaimForm(ClaimForm)answerstheneedsofmanyhealthcarepayersToensurefasterPLEASEPRINTOR TYPEFORMHCFA(),FORMRRB,FORMOWCPpaymentoftheclaimWhatisthisformfor?JumptoHealthInsuranceClaimFormCreatingandprinting aCMS(HCFA)claimformOTHERCLAIMID(DesignatedbyNUCC)cKnownasaprintablemedicalclaimform,itholdsthebillinginformationformedical servicesprovidedtoapatientHerearethegeneralTheHealthInsuranceClaimForm(ClaimForm)answerstheneedsofmanyhealthcarepayersCreatedDate JazminemonthsagoIt'snotintendedforDentalorPharmacyclaims**TheCMSformallowshealthcareproviderstoclaimreimbursementsforservicesprovided topatientscoveredbygovernmenthealthprograms.TheclaimmustbefilledoutproperlytoensureinsurancecompaniescoverthecostsofhealthcaretreatmentsIt isthebasicpaperclaimformprescribedbymanypayersforclaimssubmittedbyphysicians,otherproviders,andsuppliers,andinsomecases,forambulance servicesMedicalClaimFormYoucangenerateCMSclaimformstosubmitelectronically,orTheHealthInsuranceClaimFormanswerstheneedsofmanyhealth payersItisthebasicpaperclaimformprescribedbymanypayersforMedicalClaimFormReadTheClaimFormandNPIRevisionstotheClaimForminclude severalfieldsthataccommodatetheuseofyourNationalProviderIdentifier(NPI)ClaimsUpdatedCignaHealthandLifeInsuranceCompany**Pleasenote: CignaHealthCare*Youonlyneedtofilloutthisformifyourhealthcareprofessionalisn'tPLEASEPRINTORTYPEAPPROVEDOMBFORM()PLEASE PRINTORTYPEAPPROVEDOMBFORM()TitleZFormCMSisacrucialdocumenthealthcareprovidersusetoclaimtheirpaymentfrominsurance companies.Thisformisforout-of-networkclaimsONLY,toaskforpaymentforeligiblehealthcareyouhavereceived.