Form CMS-2384 Third Party Premium Billing Request

Form CMS-2384 Third Party Premium Billing Request

What Is Form CMS-2384?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on March 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form CMS-2384?
A: Form CMS-2384 is the Third Party Premium Billing Request form.

Q: What is the purpose of Form CMS-2384?
A: The purpose of Form CMS-2384 is to request premium billing for third-party insurance coverage for Medicare beneficiaries.

Q: Who uses Form CMS-2384?
A: Form CMS-2384 is used by health care providers and suppliers who need to bill a third-party insurance company for services provided to Medicare beneficiaries.

Q: What information is required on Form CMS-2384?
A: Form CMS-2384 requires information such as the beneficiary's Medicare information, third-party insurance information, and details of the services provided.

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Form Details:

  • Released on March 1, 2018;
  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CMS-2384 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services.

Download Form CMS-2384 Third Party Premium Billing Request

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  • Form CMS-2384 Third Party Premium Billing Request, Page 1
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