Hippaa Sample Claim Form
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1
212345
Invoice Number:
Invoice Date:
Use this form for IRIS-funded, non-HIPAA claims only.
Medicaid ID:
DOB:
Participant First Name:
Middle:
Participant Last Name:
Pre-authorization Number:
01 01 1970 John
Doe
1234567890
/
/
To be completed by provider:
Provider Name:
Provider ID (see instructions on reverse):
Billing Period Dates
ABC Corp.
12-3456789
3 1
2016
Billing Start Date:
/
/
3 31
2016
Phone:
Billing End Date:
/
/
Provider Address (street):
Provider Address (city, state, zip):
Provider Contact Person:
Participant
Discharge
City, State 54321
123 W. Street
Jane Doe
Status
123-456-7890
Phone:
If different from the service or rendering provider above:
Service dates may be grouped by month or by pay period. Invoices submitted before the due date will be processed and paid on the
next pay date. If you prefer to be paid more frequently, submit your invoices on a bi-weekly basis per the Vendor Schedule.
Billing Provider Name
Billing Provider Address
Billing Provider ID:
Admittance
Start Care Date
.
Each service line may only include dates from one calendar month. If your service dates span multiple months, use separate service
Phone:
/
/
lines. Submit claims only after services have been rendered.
Procedure/
Modifiers
Service
Service
Description
POS
Bill
Unit
Rate
Units
Billed
Revenue Code
From Date
To Date
Type
Type
Amount
CCYY-MM-DD
CCYY-MM-DD
Each/Mile/HR
Day
3/1/2016
S8990
3/31/2016
Physical Therapy
10.00 $650.00
Grouped by
$65.00
Paid V9.
month.
Day
S8990
Physical Therapy
2.00
$130.00
3/1/2016
3/12/2016
Paid V7.
$65.00
Grouped by
Day
S8990
3/13/2016 3/26/2016 Physical Therapy
pay period.
2.00
$130.00
Paid V8.
$65.00
3/31/2016
Day
S8990
6.00
$390.00
3/27/2016
Physical Therapy
Paid V9.
$65.00
John Doe
Provider Signature: ______________________________
__
TOTAL
650.00
$
Signature confirms compliance with the IRIS Medicaid Provider Service Agreement outlined on the back of this form.
Jane Doe
SAMPLE
3
31
1 6
Participant Signature: _______
_______
__
Date:
/
/ 20
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