The billing forms behind every claim
Almost every dollar in US healthcare moves on one of a few standardized claim forms. Here is a plain-language guide to the ones that matter most for practices and DME suppliers: what each one is, who uses it, and how NextRCM completes them cleanly so claims pay the first time. The layouts below are our own simplified illustrations, not the official forms.
CMS-1500 Health Insurance Claim Form
The standard claim form for physicians, suppliers, and non-institutional providers.
- What it is
- It is the paper and data standard for billing professional services and durable medical equipment to Medicare, Medicaid, and most commercial payers. Its electronic equivalent is the 837P transaction.
- Who uses it
- Physicians, therapists, independent providers, and DME suppliers billing professional or supplier claims.
- A bit of history
- The CMS-1500 (formerly the HCFA-1500) is the standard professional claim form, maintained by the National Uniform Claim Committee (NUCC). The current 02/12 version added support for ICD-10 and more diagnosis pointers.
How NextRCM handles it: We complete the CMS-1500 with accurate codes, the right DME modifiers, and diagnosis pointers that support medical necessity, then scrub it against payer edits before it goes out, so it pays on the first pass.
UB-04 (CMS-1450) Institutional Claim Form
The standard claim form for hospitals and other institutional providers.
- What it is
- It is the standard form for institutional billing, carrying the revenue codes, condition and occurrence codes, and value codes that institutional claims depend on.
- Who uses it
- Hospitals, skilled nursing facilities, home health agencies, hospices, and other facility-based providers.
- A bit of history
- The UB-04 (CMS-1450) replaced the UB-92 and is maintained by the National Uniform Billing Committee (NUBC). Its electronic equivalent is the 837I transaction.
How NextRCM handles it: We map services to the correct revenue codes and bill types, align the diagnosis and procedure coding, and check the condition and occurrence codes so institutional claims are accepted, not returned.
Advance Beneficiary Notice of Noncoverage (CMS-R-131)
The notice given when Medicare may not pay, so the patient can choose to proceed.
- What it is
- It tells a Medicare patient, before an item or service is provided, that Medicare may not pay, and lets them decide whether to accept financial responsibility. It links to the GA or GZ modifier on the claim.
- Who uses it
- DME suppliers and providers when a Medicare item or service may not meet coverage criteria.
- A bit of history
- The ABN is a CMS-standardized notice (form CMS-R-131). It protects both the beneficiary and the supplier when an item or service may be denied by Medicare.
How NextRCM handles it: We flag when an ABN is appropriate, make sure it is complete and signed before delivery, and attach the correct modifier, so a noncovered item does not turn into an unexpected write-off.
Standard Written Order / Detailed Written Order
The order a DME supplier needs on file before billing many items.
- What it is
- It is the prescriber's order that authorizes a DME item. Without a complete SWO, including the item, quantity, prescriber, and date, a DME claim is denied even when the item was appropriate.
- Who uses it
- DME suppliers, working with the ordering physician or practitioner.
- A bit of history
- Medicare consolidated several order types into the Standard Written Order (SWO). Some items still require additional documentation or a detailed written order before delivery.
How NextRCM handles it: We verify the SWO is complete and matches the claim and the proof of delivery before billing, and chase any missing element with the prescriber, so the order never becomes the reason for a denial.
Medicare DMEPOS Supplier Enrollment Application
The application a DME supplier files to enroll and bill Medicare.
- What it is
- It establishes a DMEPOS supplier's Medicare billing privileges, capturing ownership, locations, and the supplier standards the business attests to meeting. It ties back to accreditation and the surety bond.
- Who uses it
- DME suppliers enrolling with Medicare, and existing suppliers reporting changes or revalidating.
- A bit of history
- The CMS-855S is the Medicare enrollment application specific to DMEPOS suppliers, maintained by CMS. Suppliers can also complete it electronically through PECOS.
How NextRCM handles it: We prepare and track the 855S so ownership, locations, and supplier standards stay complete and consistent, and we watch revalidation dates, so an enrollment gap never quietly stops payments.
Proof of Delivery
Documentation that the billed DME item actually reached the patient.
- What it is
- It evidences that the patient received the specific item billed, on a given date, and must match the claim and the order. It is one of the elements payers most often find misaligned.
- Who uses it
- DME suppliers, for items billed to Medicare and most other payers.
- A bit of history
- Proof of delivery is a Medicare documentation requirement for DMEPOS, with defined formats for direct delivery and for shipping through a carrier.
How NextRCM handles it: We match the proof of delivery to the order and the claim, on item, quantity, and date, before billing, and flag any mismatch, so delivery is never the gap that costs the payment.
Medicare Redetermination Request
The form that opens the first level of a Medicare appeal on a denied claim.
- What it is
- It formally asks Medicare to review a denied or reduced claim, with the supporting documentation attached. It must be filed within the appeal deadline shown on the remittance.
- Who uses it
- Providers and DME suppliers appealing a Medicare denial, before escalating to reconsideration.
- A bit of history
- The CMS-20027 is the standard form for requesting a redetermination, the first level of Medicare appeal, filed with the contractor that processed the claim.
How NextRCM handles it: We work denials by root cause, assemble the documentation that answers the specific reason code, and file the redetermination on time, so recoverable revenue is not lost to a missed appeal window.
Educational, and rights-safe
The layouts above are our own simplified illustrations to explain what each form does, not reproductions of the official forms, which are maintained by bodies like the NUCC, NUBC, and CMS. We complete real claims inside the systems you already use, to HIPAA standards, and this page collects no patient health information. For the official forms and instructions, always use the current versions from the issuing body or your clearinghouse.
Billing form questions
Still have a question? Talk to our team and we'll walk through your specific situation, no pressure and no patient data needed.
Get a consultationThe CMS-1500 is the professional claim form, used by physicians, suppliers, and DME providers. The UB-04 (CMS-1450) is the institutional claim form, used by hospitals, skilled nursing facilities, home health agencies, and hospices. Most practices and DME suppliers bill on the CMS-1500.
They are the electronic equivalents of the paper forms: the 837P is the electronic CMS-1500 (professional), and the 837I is the electronic UB-04 (institutional). Almost all claims today are submitted electronically through a clearinghouse rather than on paper.
Almost always the CMS-1500 (electronically, the 837P), with the Standard Written Order and proof of delivery in the documentation behind it. The right HCPCS codes and DME modifiers on that form are what make the claim pay.
Medicare has phased out most CMNs in favor of the Standard Written Order and the supporting documentation in the medical record. We make sure each item carries the order and documentation it currently requires, rather than relying on a form that may no longer apply.
An Advance Beneficiary Notice is given before a Medicare item or service that may not be covered, so the patient can decide whether to accept financial responsibility. It links to the GA or GZ modifier on the claim and protects both the patient and the supplier.
A DMEPOS supplier enrolls using the CMS-855S application, on paper or through PECOS, which captures ownership, locations, accreditation, and the surety bond, and attests that the business meets Medicare's supplier standards. Enrollment has to be kept current through revalidation, or billing privileges can lapse.
Yes. The first level is a redetermination, requested on form CMS-20027 with the contractor that processed the claim, within the deadline shown on the remittance. If it is upheld, the next level is a reconsideration by an independent contractor. Well-documented, on-time appeals recover revenue a denial would otherwise lose.
Let us handle the forms, and the follow-up
From the CMS-1500 to the UB-04 and every DME order behind it, we complete claims cleanly so they pay the first time. Get a consultation.