What is HCFA called now?

The CMS-1500 and UB-04 are standard health insurance claim forms used in medical billing to request reimbursement from insurance payers like Medicare, Medicaid, and private companies.

The primary difference depends on who is providing the service: individual professionals or healthcare institutions.

CMS-1500 (Professional Claim Form)

• Who uses it: Individual healthcare professionals, such as doctors, nurse practitioners, physical therapists, and independent laboratories.
• What it covers: Outpatient services, office visits, and professional medical procedures.
• Structure: Contains 33 fields and maps to the electronic 837P format.
• Coding style: Uses CPT and HCPCS codes for procedures and ICD-10 codes for diagnoses.

UB-04 / CMS-1450 (Institutional Claim Form)

• Who uses it: Healthcare institutions and facilities, such as hospitals, skilled nursing facilities, hospices, and ambulatory surgical centers.
• What it covers: Inpatient stays, room and board, facility fees, and heavy equipment or operational costs.
• Structure: Contains 81 fields (form locators) and maps to the electronic 837I format.
• Coding style: Uses revenue codes, occurrence codes, and institutional-specific billing metrics alongside procedure and diagnosis codes.

You can fill out a paper claim using the official guidelines from the Medicare Claims Processing Manual and step-by-step instructions provided by the CGS Medicare CMS-1500 Tutorial.

The CMS-1500 form is split into patient/insured data (items 1–13) and physician/supplier data (items 14–33).

Patient and Insured Information (Boxes 1–13)

• Box 1 (Type of Insurance): Select the "Medicare" checkbox.
• Box 1a (Insured's ID Number): Enter the patient's Medicare Beneficiary Identifier (MBI) or HICN.
• Box 2 (Patient's Name): Write the patient’s last name, first name, and middle initial exactly as it appears on their Medicare card.
• Box 3 (Birth Date & Sex): Enter the 8-digit birth date (MM/DD/CCYY) and select M or F.
• Boxes 4, 6, and 7: Enter the insured’s name, relationship to the patient, and address if different from the patient. Leave blank if the patient is the insured ("Self").
• Boxes 12 and 13 (Signatures): Enter "Signature on File" (SOF) or secure physical/electronic signatures to authorize the release of medical info and assignment of benefits.

Physician and Supplier Information (Boxes 14–33)

• Box 17: Enter the name and National Provider Identifier (NPI) in 17b of the referring or ordering physician.
• Box 21 (Diagnosis Code): Enter the ICD-10 diagnosis codes using the appropriate indicator (0 for ICD-10).
• Box 24 (Service Lines A–J): Enter individual dates of service, place of service codes (e.g., 11 for office), HCPCS/CPT procedure codes, charges, units, and the rendering provider's NPI. Do not use commas or dollar signs in charge fields.
• Box 25: Enter the provider's Federal Tax ID (EIN or SSN).
• Boxes 32 and 33: Provide the service facility location name/address (Box 32) and the billing provider's info and NPI (Box 33).
• Box 31: Provide the signature of the physician or supplier along with the date.

The Centers for Medicare & Medicaid Services (CMS) finalized major updates for Calendar Year (CY) 2026 focusing on payment adjustments, the Medicare Advantage program, and streamlined reporting.

Medicare Advantage and Part D Updates

• Payment Increases: Government payments to Medicare Advantage (MA) plans increase by an average of 5.06% (about $25 billion).
• Benefit Alignment: Part D rules align with the redesigned benefit structure and integrate provisions from the Inflation Reduction Act to manage prescription drug cost-sharing.
• Prescription Payment Plan: Codifies operations for the Medicare Prescription Payment Plan, featuring an automatic election renewal unless the enrollee opts out.

Physician Fee Schedule (PFS) Changes

• Conversion and Rates: Implements a 2.7% increase to the Medicare Economic Index (MEI) and updates valuation rules under the CY 2026 Physician Fee Schedule Final Rule.
• Telehealth and Supervision: Expands covered telehealth services, removes specific frequency limits, and adopts virtual direct supervision rules.
• Coding Adjustments: Expands the G2211 evaluation and management add-on code to home and residence visits, and introduces new behavioral health and Advanced Primary Care Management (APCM) codes.

Administrative and Regulatory Reductions

• Quality Measures: Reduces overall administrative reporting burden by lowering the number of quality measures by 5% year-over-year.
• Inpatient-Only List: Continues the three-year phase-out of the inpatient-only list by removing nearly 300 predominantly musculoskeletal procedures.

The CMS-1500 form is used by non-institutional healthcare providers, physicians, and suppliers to bill Medicare for professional and outpatient services.

Who Uses the CMS-1500 Form

• Physicians and doctors in private or group practices
• Non-institutional providers like physical therapists, occupational therapists, and speech-language pathologists
• Clinical psychologists and behavioral health professionals
• Nurse practitioners and physician assistants
• Medical suppliers and ambulance service providers

Important Details

• Purpose: It is the standard paper claim form used when a provider qualifies for an exception or waiver to submit paper claims instead of the electronic 837P format.
• Exclusions: Hospitals and skilled nursing facilities use a different form (the UB-04) for institutional billing.

The Centers for Medicare & Medicaid Services (CMS) was previously known as the Health Care Financing Administration (HCFA) until it was renamed in 2001.

Background

• Founded: Established in 1977 as the HCFA under the Carter administration.
• Renamed: Changed to CMS in June 2001 by then-HHS Secretary Tommy Thompson to emphasize a focus on customer service and health care quality.
• Function: The federal agency administers Medicare, works with states on Medicaid and the Children's Health Insurance Program (CHIP), and oversees the Health Insurance Marketplace.