CMS-1500 Claim Form Instructions

Disclaimer

This information release is the property of Noridian. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided "as is" without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian Healthcare Solutions (Noridian) and the CMS. The most current edition of the information contained in this release can be found on the Noridian website and the CMS website.

The identification of an organization or product in this information does not imply any form of endorsement.

The CMS-1500 Form (Health Insurance Claim Form) is sometimes referred to as the AMA (American Medical Association) form. The CMS-1500 Form is the prescribed form for claims prepared and submitted by physicians or suppliers, whether or not the claims are assigned. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.

The National Uniform Claim Committee (NUCC) changed the Form CMS-1500, and the revised form received White House Office of Management and Budget (OMB) approval on June 10, 2013. The revised form is version 02/12 and has replaced the previous version of the form 08/05.

The CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 26 was used to create this tutorial. The following instructions apply to the CMS-1500 Claim Form versions 08/05 and 02/12.

Legend Description
MM Month (e.g., December = 12)
DD Day (e.g., Dec 15 = 15)
YY 2 position Year (e.g., 2006 = 06)
CCYY 4 position Year (e.g., 2006 = 2006)
(MM | DD | YY) or (MM | DD | CCYY) A space must be reported between month, day, and year (e.g., 12 | 15 | 06 or 12 | 15 | 2006). This space is delineated by the dotted vertical line on the CMS-1500 Form
(MMDDYY) or (MMDDCCYY) No space must be reported between month, day, and year (e.g., 121506 or 12152006). The date must be recorded as one continuous number.

Reminder: Providers and suppliers have the option of entering either a 6 or 8-digit date in items 11b, 14, 16, 18, 19, or 24A. The format chosen must be consistent throughout these items. Intermixing the two formats on the claim is not allowed. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19, and a 6-digit date for item 24A. Items 12 and 31 are exempt from this requirement.

NOTE: Throughout these instructions, you will notice that some items are bolded and some are in italics. Noridian has used boldface type to emphasize certain points and provided additional clarification on items through the use of italics.

 
Item Instructions
Item 1 Type of Health Insurance Coverage Applicable to the Claim
Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Item 1a

Insured's ID Number
(Medicare ID)
This is a required field. Enter the patient's Medicare ID whether Medicare is the primary or the secondary payer. An invalid Medicare ID will cause a claim to deny or be rejected as unprocessable.
Item 2 Patient's Name
This is a required field . Enter the patient's last name, first name, and middle initial, if any, as it appears on the patient's Medicare card (e.g., Jones John J). Include only one space between the last name, first name, and middle initial. If the name is not an identical match, the claim will be rejected as unprocessable. Do not submit extra spaces, nicknames, or descriptions such as Jr., Sr., deceased, or the estate of (unless indicated on the Medicare card).

Do not extend the beneficiary's name beyond the confines of this box.
Item 3 Patient's Birth Date and Sex
Enter the patient's 8-digit birth date (MM | DD | CCYY) and sex. Only one box should be indicated: either M or F. Marking both or neither will cause the claim to be rejected as unprocessable.
Item 4 Insured's Name
If Medicare is primary, leave blank . If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME.
Item 5 Patient's Address and Telephone Number
This is a required field and must be filled in completely. Enter the patient's permanent mailing address as listed with Social Security and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number.
Item 6 Patient's Relationship to Insured
If Medicare is primary, leave blank. Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
Item 7 Insurance Primary to Medicare, Insured's Address and Telephone Number
Complete this item only when items 4, 6, and 11 are completed. Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME.
Item 8 Reserved for NUCC Use
Leave blank.
Item 9 Medigap Benefits, Other Insured's Name
If no Medigap benefits are assigned, leave blank. Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. This field may be used in the future for supplemental insurance plans.

NOTE: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the participating physician or supplier.

Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. (See chapter 28 of the Medicare Claims Processing Manual.)

Medigap - Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in Section 1882(g)(1) of Title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.

Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.
Item 9a Medigap Benefits, Other Insured's Policy or Group Number
If no Medigap benefits are assigned, leave blank. Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP. Do not enter other types of insurance (e.g., supplemental).

NOTE: Item 9d must be completed if the provider enters a policy and/or group number in item 9a.
Item 9b Reserved for NUCC Use
Leave blank.
Item 9c Reserved for NUCC Use
Leave blank.
Item 9d Medigap Benefits, Insurance Plan/Program Name, PAYERID Number
Enter the nine-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

If the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, the participating provider or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d.

A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary's claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See chapter 28 Section70.6.4 for more information concerning the COBA Medigap claim-based crossover process.)

NOTE: The configuration of the PAYERID is alpha numeric and up to 9 digits.
Items
10a-10c 		Condition Relationship? Employment, Auto Liability, or Other Accident
Check "YES" or "NO" by placing an (X) in the center of the box to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES," indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.
Item 10d Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD.
Item 11 Insured's Policy Group or FECA Number

THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.
If there is insurance primary to Medicare for the service date(s), enter the insured's policy or group number within the confines of the box and proceed to items 11a-11c. Items 4, 6, and 7 must also be completed. If item 11 is left blank, the claim will be denied as unprocessable.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11.

If there is no insurance primary to Medicare, do not enter "n/a," "not," etc., enter the word NONE within the confines of the box and proceed to item 12.

If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word NONE and proceed to item 11b.

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word NONE in item 11 of the CMS-1500 Form, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:
  • Group Health Plan Coverage
    • Working Aged (Type 12);
    • Disability (Large Group Health Plan - Type 43); and
    • End Stage Renal Disease (ESRD - Type 13);
  • No Fault (Type 14) and/or Other Liability (Type 47); and
  • Work-Related Illness/Injury:
    • Workers' Compensation (Type 15);
    • Black Lung (Type 41); and
    • Veterans Benefits (Type 42).
NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a policy or group number must be entered in this item. In addition, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Pub. 100-05, Medicare Secondary Payer Manual, Chapter 3.) Without an attached EOB from the primary insurance, the claim will be denied.
Item 11a Insured's Date of Birth and Sex
This item must be completed if a policy or group number is reported in item 11 AND is different from the date in item 3. Enter the insured's 8-digit birth date (MM | DD | CCYY) and sex if different from item 3.
Item 11b Insurance Primary to Medicare, Employer's Name
Provide this information to the right of the vertical dotted line: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) retirement date proceeded by the word "RETIRED."
Item 11c Insurance Plan/Program Name
This item must be completed if a policy or group number is submitted in item 11. Enter the nine-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer's program or plan name. If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB. Please include the telephone number of the primary payer. This is required if there is insurance primary to Medicare that is indicated in item 11.
Item 11d Leave blank. Not required by Medicare.
Item 12 Patient's or Authorized Person's Signature
The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alphanumeric date (e.g., January 1, 2006) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements." If the patient is physically or mentally unable to sign, a representative specified in the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements" may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient's representative revokes this arrangement.

NOTE: This can be Signature on File and/or a computer generated signature. The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.
Item 13 Medigap Benefits, Insured's/Authorized Person's Signature
The patient's signature or the statement "signature on file" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient's signature or a "signature on file" is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or "signature on file" in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

In addition, the signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
Item 14 Leave blank. Not required by Medicare.
Item 15 Leave blank. Not required by Medicare.
Item 16 Leave blank. Not required by the DME MAC
Item 17 Name of the Referring or Ordering Physician
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

Additional instructions for form version 02/12: Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:
DN = Referring Provider
DK = Ordering Provider
DQ = Supervising Provider

Do not extend the name beyond the confines of this box. Only enter what will fit into item 17. Do not run name into item 17a or 17b. The ordering physician’s name should be in this exact format: First name, last name, no middle initial and no credentials. An invalid physician name will cause a claim to deny or be rejected as unprocessable.
Item 17a Leave blank (effective May 23, 2008, 17a is not to be reported, but 17b MUST be reported when a service was ordered or referred by a physician)
Item 17b NPI of the Referring/Ordering Physician
Enter the NPI of the referring, ordering, supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.
Item 18 Leave blank. Not required by the DME MAC
Item 19 Narrative Field
This is a required field for the purposes outlined below.
  • Enter the drug's name, strength, and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
  • Enter a concise description of an "unlisted procedure code" or a "not otherwise classified" (NOC) code within the confines of this box. An attachment may also need to be submitted to help expedite claim processing. If more than one unlisted procedure code is reported on the claim, precede each description in item 19 with the line item number that corresponds to the line that contains the NOC code. This will enable claims processing staff to determine the correct description for each unlisted procedure code. If billing the same unlisted procedure code more than once on the claim, you may need to indicate the charges of the procedure codes to indicate which description belongs to each line.
  • Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in item 24D. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item. Modifier 99 is only appropriate when more than four modifiers are necessary per claim line. When four or less modifiers apply, each modifier can be entered in the existing space in item 24D on the CMS-1500 Form.
  • Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a non-participating provider/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.
Note paper claim submission: Enter "see attached" if attaching documents and on attachments make a note to "refer to Item 19" This will help ensure all documentation matches up at time of claim processing.
Item 20 Leave blank. Not required by the DME MAC.
Item 21

Patient's Diagnosis/Condition
Do not insert a period in the ICD-10-CM code.
Item
21 ICD Ind.		 Enter "0"
Item 22 Leave blank. Not required by Medicare
Item 23 Prior Authorization Number
Enter the 14-byte Unique Tracking Number (UTN), provided within the decision letter. Each HCPCS code has a separate UTN
  • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1), one UTN submitted per claim line
Note: Item 23 can contain only one UTN. Any additional UTNs obtained should be reported on a separate CMS-1500 Form.
Item 24 Service Line
The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.

When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g., N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space fill the remaining positions (e.g. UN2 or F2999999).
Item 24A Date of Service
This is a required field. Enter a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date for each procedure, service, or supply within the confines of this box. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G. Return as unprocessable if a date of service extends more than 1 day and a valid "to" date is not present.
Item 24B Place of Service
This is a required field. Enter the appropriate 2-digit place of service code(s) from the list provided in Section 10.5 of the Medicare Claims Processing Manual, Chapter 26. Identify the location, using a place of service code, for each item used or service performed.

Note: For DMEPOS claims, the place of service is considered to be the place where the beneficiary will primarily use the DMEPOS item.
Item 24C Leave blank. Not required by Medicare.
Item 24D

Procedures, Services, or Supplies Code
This is a required field.

Procedure Code: Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code.

Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in item 19 if a coherent description can be given within the confines of that box.

  • Narrative added to claim:
    • Description of the item or service
    • Manufacturer name
    • Product name, model name and number
    • Supplier Price List (PL) amount (this is the same amount billed on the claim line)
    • HCPCS code of related item (if applicable)
    • If Repair part, HCPCS code of item being repaired

Example

  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), MSRP $XXX.XX
  • Indicate what it is, what is it for, what is MSRP

Otherwise, an attachment must be submitted with the claim with additional information submitted.

Noridian will return as unprocessable if an "unlisted procedure code" or a "not otherwise classified" (NOC) code is indicated in item 24D, but an accompanying narrative is not present in item 19 or on an attachment with that information.

Modifiers: When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 Form has the ability to capture up to four modifiers. If more than four modifiers are needed, use modifier 99 (overflow) as the fourth modifier and enter the additional modifiers in item 19.

  • Modifier placement
    • First position - Pricing modifiers. i.e. RR, KH, KI, KJ, NU
    • Second position - Modifiers to indicate requirements specified in the medical policy have been met. i.e. KX
    • Other positions - Any additional informational modifiers required
  • Please utilize the Modifier Lookup Tool for reference on potential modifiers for HCPCS codes

Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits. Some modifiers cause automated pricing changes, while others are used to convey information only. They are not required on all HCPCS codes; however, if required and not submitted, the claim will deny as unprocessable. Be sure to distinguish between zeros and the letter "O". Hyphens or any other separators should not be used between procedure codes and modifiers.

Only uppercase characters should be used for procedure codes and modifiers.
Item 24E Diagnosis Code Reference Number

This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in Item 21 to relate the date of service and the items or services rendered to the primary diagnosis. Enter only one reference number/letter per line item. When multiple items or services are performed, enter the primary reference number for each service, either a 1, a 2, a 3, or a 4.

If a situation arises where two or more diagnoses are required for a procedure code, the provider shall reference only one of the diagnoses in item 21.
Item 24F Charge Amount
Enter the charge for each listed service. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed.

Note for electronic claim submissions: The maximum number of characters that can be submitted in any dollar amount field is seven characters. Claims containing a dollar amount more than $99,999.99 will be rejected. Two claims must be submitted when more than seven characters exist in the total of the claim. Follow instructions below for totals that contain more than seven characters.

Claim 1
  • Submit the service with an acceptable dollar amount (< 9999999.) See example below, splitting total. (Do not use dollar signs, decimals, dashes, commas for dollar amounts.)
  • In the narrative field, identify this as, "Claim 1 of 2; Dollar amount exceeds charge line amount."
Claim 2
  • Enter the charge as the remaining dollar amount from the total split.
  • In the narrative field, identify this as, "Claim 2 of 2; Remaining dollar amount from Claim 1 amount exceeds charge line amount."
You must note in the narrative the reason why the claim is split this way. It will deny as a duplicate without the narrative.
  • Narrative must be added in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form in the narrative field.
Also, when splitting the charge of the service, be sure the dollar amounts are slightly different, as this will prevent the system from assuming the two claims are an exact duplicate.

Example: If the charge for a service is $100,000.00, submit the charge on Claim 1 as 5200000; on Claim 2 submit the charge as 4800000. Ensure the narrative is added as above. (Do not use dollar signs, decimals, dashes, commas for dollar amounts.)
Item 24G Days or Units
Enter the number of days or units. If only one service is performed, the numeral 1 must be entered.

Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies). When multiple services are provided, enter the actual number provided.

For instructions on submitting units for oxygen claims, see Chapter 20, Section 130.6 of the Medicare Claims Processing Manual.

Do not place zeros before or after the number of units (e.g., a service of 1 should not be billed as 010; it should be billed as 1. Indicate only whole numbers, e.g., do not bill 1.5).

NOTE: This field should contain at least 1 day or unit. The DME MAC will default to "1" unit when the information in this field is missing to avoid returning as unprocessable.
Item 24H Leave blank. Not required by Medicare. Entering information in this item may cause delays in claims processing.
Item 24I Leave blank. Not required by the DME MAC.
Item 24J Enter your NPI number in the lower unshaded portion.

NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.
Item 25 Provider or Supplier Federal Tax ID (Employer Identification Number)
Enter the provider of service or supplier Federal Tax ID (Employer Identification Number) or Social Security Number. Enter an (X) in the appropriate box to indicate which number is being reported. Only one box can be marked. Do not enter hyphens or spaces. Medicare providers are not required to complete this item for crossover purposes since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim. However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed.
Item 26 Patient's Account Number
This field is optional to assist the provider in patient identification. Enter the patient's account number assigned by the provider's of service or supplier's accounting system. As a service, any account numbers entered here will be returned to the provider. If an account number is entered in this item, it will appear on the provider remittance notice/advice.
Item 27 Accept Assignment?
This is a required field, even if you are a participating provider. Check the appropriate box with an (X) to indicate whether the provider of service or supplier accepts assignment of Medicare benefits or not. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on an assignment basis (the services applicable to DME MAC are bolded):
  • Clinical diagnostic laboratory services;
  • Physician services to individuals dually entitled to Medicare and Medicaid;
  • Participating physician/supplier services;
  • Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
  • Ambulatory surgical center services for covered ASC procedures;
  • Home dialysis supplies and equipment paid under Method II;
  • Ambulance services;
  • Drugs and biologicals; and
  • Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.
Item 28 Total charges for services on claim
Enter the total charges for the services (i.e., total of all charges in 24F). Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 Form should have its own total.
Item 29 Total amount the patient paid on the covered services only
Enter the total amount the patient paid on the covered services only. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 Form should have its own total.

Do not include the amount paid by the primary insurance, co-insurance, deductibles, account balance, or payments on previous claims in this item.

NOTE: If any dollar amount is entered here, part or all of the payment will go directly to the patient, even if you are a participating provider.
Item 30 Leave blank. Not required by Medicare.
Item 31 Signature of Provider of Service or Supplier
This is a required field. Enter the signature of the provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 2022) the form was signed.

NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature. Noridian is unable to process claims without the required signature and date listed in item 31. If left blank, the claim will be rejected as unprocessable.

The signature and date must be completely within the confines of this box. Additional acceptable signatures include: Signature stamp and computer generated signature. Noridian is unable to process claims without the required signature and date listed in item 31. If left blank, the claim will be rejected as unprocessable.
Item 32 Name and Address of Facility Where Services Were Rendered
Enter the name, address, and ZIP code of the facility if the services were furnished in a physician's office, hospital, clinic, laboratory, or facility other than the patient's home. Only one name, address, and ZIP code may be entered in the box. If additional entries are needed, separate claim forms shall be submitted.

Enter the name and address information in the following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code

NOTE: Enter a complete address for the location where the services were performed. A PO Box is not acceptable. Do not include telephone numbers, commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between the city and the state postal code. When entering a 9-digit ZIP code, include the hyphen.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States.

For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DME only). This field is required. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.
Item 32a NPI of Service Facility
If required by Medicare claims processing policy, enter the NPI of the service facility.
Item 32b NOTE: Effective May 23, 2008, Item 32b is not to be reported.
Item 33 Provider's/ Supplier's Telephone Number, Billing Name, Address, and ZIP Code.
Enter the provider of service/supplier's billing name, address, ZIP Code, and telephone number. This is a required field.

Enter the name and address information in the following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code
Item 33a NPI of Billing Provider (Supplier) or Group
Enter the NPI of the billing provider or group. This is a required field.

NOTE: Submitting an invalid NPI in this item will cause the claim to be rejected as unprocessable.
Item 33b Effective May 23, 2008, Item 33b is not to be reported (unless billed via Indirect Payment Procedure (IPP); if you are an IPP biller, please follow IPP billing guidelines).

To purchase claim forms, contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies, and/or office supply stores.

Last Updated Jun 21 , 2024