department of labor and industries …cms 1500 - (formerly l&i health ins claim form) department...
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![Page 1: DEPARTMENT OF LABOR AND INDUSTRIES …CMS 1500 - (formerly L&I Health Ins Claim form) DEPARTMENT OF LABOR AND INDUSTRIES CLAIMS SECTION PO BOX 44269 OLYMPIA WA 98504-4269 00987654302](https://reader034.vdocument.in/reader034/viewer/2022042416/5f31c1ccaaa4487ef5426e30/html5/thumbnails/1.jpg)
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CMS 1500 - (formerly L&I Health Ins Claim form)
DEPARTMENT OF LABOR AND INDUSTRIESCLAIMS SECTIONPO BOX 44269OLYMPIA WA 98504-4269
00987654302
Doe, Jane, A. ✘ DOE, JANE, A.
199 SOUTH FRANKLIN STREET 199 SOUTH FRANKLIN STREET
WASHINGTON PA
YD
WASHINGTON PA
16111 724 555-1212 16111 724 555-1212
10 15 09
UPMC FOR YOU
Z00 129
10 15 11 99383 EP
11 99173 EP
11 92552 EP
85 00 03
191919191 25647651
724 555-1212
DOCTOR'S OFFICE 66 PEDIATRIC STREET, WASHINGTON, PA 16111
Example of a completed claim for a 6-year EPSDT visit
UPMC for You encourages electronic claims submissions.
1a. INSURED’S ID NUMBER
#
25. FEDERAL TAX ID NUMBER SSN EIN
1111111111
15 10 15 15
10 15 15 10 15 15
10 15 15 10 15 15
![Page 2: DEPARTMENT OF LABOR AND INDUSTRIES …CMS 1500 - (formerly L&I Health Ins Claim form) DEPARTMENT OF LABOR AND INDUSTRIES CLAIMS SECTION PO BOX 44269 OLYMPIA WA 98504-4269 00987654302](https://reader034.vdocument.in/reader034/viewer/2022042416/5f31c1ccaaa4487ef5426e30/html5/thumbnails/2.jpg)
Please do not staple in this area
CMS 1500 - (formerly L&I Health Ins Claim form)
DEPARTMENT OF LABOR AND INDUSTRIESCLAIMS SECTIONPO BOX 44269OLYMPIA WA 98504-4269
Example of a completed claim for a 2-3 month EPSDT visit
UPMC for You encourages electronic claims submissions.
If yes
CA
RR
IER
PATI
ENT
AN
D IN
SUR
ED IN
FOR
MA
TIO
NPH
YSIC
IAN
OR
SU
PPLI
ER IN
FOR
MA
TIO
N
NPI NPI
00111111101
DOE, JOHN, H ✘ DOE, JOHN, H
1 FRONT STREET 1 FRONT STREET
PITTSBURGH PA PITTSBURGH PA
16111 724 555-1212 16111 724 555-1212
01 15
UPMC FOR YOU
Z00 129
10 15 11 99381 EP 85 00 03
191919191 25647651
724 555-1212
123 Pediatrics 999 Johnston Street, Pittsburgh, PA 15444
9876543219
1a. INSURED’S ID NUMBER
#
25. FEDERAL TAX ID NUMBER SSN EIN
08
15 10 15 15