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Invoice Forms

The Children with Medical Handicaps Program uses three basic billing forms:

1.    UB 04/CMS 1450 – Used solely for BCMH-approved hospital inpatient/outpatient billing.

2.    American Dental Association (ADA) billing form - Used for basic dental services.

3.    CMS 1500 – Used as a multipurpose basic medical billing form to bill the following BCMH-approved medical services:

  • Physician services and hospital visits (Note:  a copy of the operative report should be attached to all claims for surgical procedures)
  • Orthodontic services
  • Equipment
  • Medical supplies
  • Durable medical equipment
  • Orthotics
  • Prosthetics
  • Vision services
  • Hearing services and hearing aids
  • Therapy services
  • Independent lab services
  • Other basic medical services

Last Updated: 6/29/2017