Prialt.comAn effective non-opioid treatment option for severe chronic pain
 hcp home  product info safety prescribing information elan pain information center prialt.com
Search  
  Go Advanced
   
 


               




Forms and Documents

CMS-1450 Form 

Description:
Most hospitals use the CMS-1450 form (or the electronic equivalent) for hospital outpatient services. 

Downloads:
Example CMS-1450 form(133kb pdf)
CMS-1450 Form(18kb pdf)

CMS-1500 Form 

Description:
Most physician offices use the CMS-1500 form (or the electronic equivalent) to submit claims to local Part B Medicare carriers, state Medicaid programs, and many commercial insurers. 

Downloads:
Example CMS-1500 form(219kb pdf)
CMS-1500 form(361kb pdf)

Click here for samples of Medical Necessity and Denied Claims letters.

A copy of the complete Reimbursement Guide is available for download.