Sample CMS-1500 Claim Form for Office Billing: KEYTRUDAВ® (pembrolizumab) for Injection 50 mg CARRIER Note: for and questions on billing if a portion of a package is wasted, consult the applicable payorвЂ™s policy regarding wastage. Save Print Options HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA PICA MEDICARE MEDICAID TRICARE CHAMPVA (Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) 2. PATIENTвЂ™S NAME (Last Name, First Name, Middle Initial) 3. PATIENTвЂ™S BIRTH DATE MM DD YY 5. PATIENTвЂ™S ADDRESS (No., Street) OTHER 1a. INSUREDвЂ™S I.D. NUMBER FECA BLK LUNG (ID#) GROUP HEALTH PLAN (ID#) (ID#) 4. INSUREDвЂ™S NAME (Last Name, First Name, Middle Initial) SEX M F 7. INSUREDвЂ™S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Spouse Child Other 8. RESERVED FOR NUCC USE ( STATE CITY TELEPHONE (Include Area Code) ZIP CODE (For Program in Item 1) TELEPHONE (Include Area Code) ZIP CODE ( ) ) 9. OTHER INSUREDвЂ™S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTвЂ™S CONDITION RELATED TO: 11. INSUREDвЂ™S POLICY GROUP OR FECA NUMBER a. OTHER INSUREDвЂ™S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSUREDвЂ™S DATE OF BIRTH MM DD YY YES NO b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? PLACE (State) YES Box 19 F b. OTHER CLAIM ID (Designated by NUCC) NO c. INSURANCE PLAN NAME OR PROGRAM NAME YES d. INSURANCE PLAN NAME OR PROGRAM NAME SEX M NO 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Enter the following: YES NO If yes, complete items 9, 9a, and 9d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSONвЂ™S SIGNATURE I authorize вЂў Drug name: [KEYTRUDA (pembrolizumab)] 12. PATIENTвЂ™S OR AUTHORIZED PERSONвЂ™S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. вЂў Route of administration below. Box 21 вЂў NDC: 0006-3029-02 SIGNED DATE SIGNED EnterMMappropriate ICD-9-CM diagnosis code(s) DATE 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHERвЂў 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION вЂў The dosage provided MM YY DD YY DD MM DD MM YY DD YY QUAL. TO FROM QUAL. 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD DD MM YY YY FROM TO 17a. 17b. NPI 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) A. E. I. 24. A. MM YY B. C. PLACE OF SERVICE EMG CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER H. L. K. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER Box 24 E$ CHARGES NO вЂў Record the relevant diagnosis pointer from Box 21 22. RESUBMISSION D. G. F. J. DATE(S) OF SERVICE From To YY MM DD DD ICD Ind. C. B. E. DIAGNOSIS POINTER G. F. $ CHARGES DAYS OR UNITS H. J. RENDERING PROVIDER ID. # I. EPSDT ID. Family Plan QUAL. 1 NPI 2 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 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.) SIGNED DATE NPI Box 24 D NPI вЂў U se the appropriate unspecified HCPCS code toNPI bill for27.KEYTRUDA (pembrolizumab) ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 26. PATIENTвЂ™S ACCOUNT NO. $ $ YES NO вЂў The infusion time corresponds to CPT code 96413 ( For NPI NUCC Instruction Manual available at: www.nucc.org 30. Rsvd.for NUCC Use govt. claims, see back ) 32. SERVICE FACILITY LOCATION INFORMATION a. Box 24 G вЂў W hen using an unspecified HCPCS code, enter only 1 unit inNPI this field 3 вЂў When using an unspecified HCPCS code, enter 4 the NDC 0006-3029-02, preceded by вЂњN4,вЂќ in this gray space 5 6 PATIENT AND INSURED INFORMATION 1. PHYSICIAN OR SUPPLIER INFORMATION www.nucc.org b. PLEASE PRINT OR TYPE 33. BILLING PROVIDER INFO & PH # a. NPI ( ) b. APPROVED OMB-0938-1197 FORM 1500 (02-12) Layout by Fiachra Forms http://fiachraforms.com/quickstart_CMS1500_PDF.html The suggestions contained on this form are compiled from sources believed to be accurate for the Medicare Part B program, but Merck makes no representation that the information is accurate or that it will comply with the requirements of any particular Medicare Administrative Contractor (MAC) or payor. You are solely responsible for determining the billing and coding requirements applicable to any payor or MAC. Diagnosis codes should be selected only by a health care professional. The information provided here is not intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Billing and coding requirements may vary or change over time, so it is important to regularly check these requirements with each payor or MAC. Merck and its agents make no warranties or guarantees, express or implied, concerning the accuracy or appropriateness of this information for your particular use and caution that changes in public and private payor billing requirements occur frequently. The use of this information does not guarantee payment or that any payment received will cover your costs. ONCO-1108274-0009 08/14