Kan. Medical Assistance Program Hospice Fee-for-Service Provider Manual § 7000

Updated 12/15

Introduction to the CMS 1500 Claim Form

Hospice providers of must use the CMS 1500 paper or equivalent electronic claim form when requesting

payment for medical services and supplies provided under KMAP. Claims can be submitted on the

KMAP secure website or billed through Provider Electronic Solutions (PES). When a paper form is

required, it must be submitted on an original, red claim form and completed as indicated or it will be

returned to the provider.

An example of the CMS 1500 and instructions are available on the KMAP public and secure websites on

the Forms page under the Claims (Sample Forms and Instructions) heading.

Any of the following billing errors may cause a CMS 1500 paper claim to deny or be sent back to

the provider:

• Sending a CMS 1500 claim form carbon copy.

• Sending a KanCare paper claim to KMAP.

• Using a PO Box in the Service Facility Location Information field.

Submission of claim

Send completed first page of each claim and any necessary attachments to:

Office of the Fiscal Agent

PO Box 3571

Topeka, Kansas 66601-3571