Ahca Form 5000-3527 - Medicare Part C - Medicaid Cms-1500 Crossover Invoice printable pdf download

Ahca Form 5000-3527 - Medicare Part C - Medicaid Cms-1500 Crossover Invoice

STATE OF FLORIDA

MEDICARE PART C - MEDICAID

CMS-1500 CROSSOVER INVOICE

Use a separate form for each Medicare Part C crossover claim.

Medicaid

Last Name

First Name

Medicare

Recipient ID#

(first 2)

(first 3)

Date Paid

From DOS CPT/HCPC

Allowed

Deductible

Co-Pay

Co-insurance

Medicare Paid

*If more than 24 detail lines are needed, please submit additional invoice forms.

page

Medicaid

Provider #

By signing below, I certify that the foregoing information is accurate and complete, and understand that falsifying essential

information to receive payment from federal and state funds requested by this form may, upon conviction, be subject to fine and

imprisonment under applicable federal and state laws. I hereby agree to keep such records as are necessary to disclose fully the

event of services provided to individuals under the state's Title XIX plan and to furnish information regarding any payment claimed

for providing such services as the state agency may request. I further agree to accept as payment in full the amount paid by the

Medicaid program for claims submitted, with the exception of authorized copayment.

Provider Name and Address

Provider Signature

Date

Mail with accompanying CMS-1500 to:

CMS-1500 Crossover Claims

P.O. Box 7074

Tallahassee, FL 32314-7074

AHCA Form 5000-3527 6/12

Incorporated by reference in 59G-5.020, F.A.C.

Ahca Form 5000-3527 - Medicare Part C - Medicaid Cms-1500 Crossover Invoice