• Claim Form (CMS 1500) – required for reimbursement to provider

    • Submit the original instead of a copy
    • Make sure it is completely filled out, including the taxonomy for both “rendering provider” and “billing provider”
    • Put the service code for the exam fee (99499) on a claim form of its own, other services on a different claim form
  • CMEP Consent Form (Spanish version here) – this must be COMPLETELY filled out to be eligible for reimbursement
  • Medical Report Form – required for reimbursement to provider [Opening this file might ask you to get the updated version of Adobe Reader, but you might be able to try to click the “Open With Different Viewer” button at the top, right corner of the PDF window and see if that corrects the problem. Also, we have reports of being able to open it using Internet Explorer with no issues, but with Chrome and Firefox it would not open.] If you have difficulty opening the editable form, please find a scanned version of the report here.
  • Checklist (must be included with all cases, regardless of payment source, for reimbursement)
  • Case Conference Report Form – should be included with the above forms for reimbursement of case conference time, if applicable
  • Medical Provider Billing Instructions