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CMS-1500 Claim Form Tutorial - Version 02/12

CMS 1500 Form

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. Insured's ID Number (Patient's Medicare Health Insurance Claim Number - HICN) This is a required field. Enter the patient's HICN whether Medicare is the primary or the secondary payer. Be sure to include the suffix and do not use spaces and/or dashes. (Example of proper HICN submission: 123456789A) An invalid HICN will cause a claim to deny or be rejected as unprocessable. If a patient's HICN begins with an alpha character, their claims must be filed to Railroad Medicare. The address is indicated here. Palmetto Government Benefits Administration PO BOX 10066 Augusta GA 30999 Note: Noridian Administrative Services (Noridian) is prohibited from forwarding such claims. 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. 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. 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. Patient's Address and Telephone Number This is a required field and must be filled in completely. Enter the patient's mailing address 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. 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. 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. Reserved for NUCC Use Leave blank. 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 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. Reserved for NUCC Use Leave blank. Reserved for NUCC Use Leave blank. 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. Otherwise, the Medicare carrier cannot forward the claim information to the Medigap insurer. NOTE: The configuration of the PAYERID is alpha numeric and up to 9 digits. Noridian assigns five digit alpha numeric or numeric PAYERID numbers rather than nine digit numbers. {C}{C}Condition Relationship? Employment, Auto Liability, or Other Accident Check Leave blank. Not required by Noridian. Insured's Policy Group or FECA Number Note: All claims can be submitted electronically. For more information pleaser refer to the EDISS web site. 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. ... 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. 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 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. Leave blank. Not required by Medicare. 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 Chapter 1, Medigap Benefits, Insured's/Authorized Person's Signature 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. NOTE: This can be Signature on File and/or a computer generated signature. Date of Current Illness/Injury/Pregnancy For current illness, injury, or pregnancy, enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date. For chiropractic services, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of x-ray (if used to demonstrate subluxation) in item 19. Leave blank. Not required by Medicare. Dates Patient Unable to Work in Current Occupation If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when the patient is unable to work. An entry in this field may indicate employment related insurance coverage. Enter the name of the referring or ordering physician Enter one of the following qualifiers to the left of the dotted vertical line, as appropriate, to identify the role that the physician (or non-physician practitioner) is performing: DN = Referring Provider DK = Ordering Provider DQ = Supervising Provider NOTE: 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. NOTE: The UPIN Registry was discontinued May 23, 2008. Effective May 23, 2008 Only an NPI may be entered in any provider identifier fields on claims submitted on or after May 23, 2008. Claims will be rejected when submitted with a Medicare legacy number (PIN/PTAN) or a UPIN in any provider identifying field on or after May 23, 2008. Service furnished as a result of, or subsequent to, a related hospitalization Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization. Narrative Field This is a required field for the purposes outlined below. Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date the patient was last seen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physician providing routine foot care submits claims. ... Diagnostic and Purchased Tests This is a required field when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the Patient's Diagnosis/Condition Enter the patient's diagnosis/condition to the highest level of specificity for the date of service. Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to October 1, 2015. It may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set). The Leave blank. Not required by Medicare Prior Authorization Number This is a required field for the purposes outlined below. Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval. Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable. ... 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. At this time, the shaded area in 24A through 24H is not used by Medicare. Future guidance will be provided on when and how to use this shaded area for the submission of Medicare claims. NOTE: For more information on how to fill out a specific section of box 24, mouse over the box headings above line item 1. 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 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: When a service is rendered to a hospital inpatient, use the Leave blank. Not required by Medicare. Procedures, Services, or Supplies Code This is a required field. Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 Form has the ability to capture up to four modifiers. Enter the specific procedure code without a narrative description. However, when reporting an 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 procedures performed to the primary diagnosis. Enter only one reference number/letter per line item. When multiple services are performed, enter the primary reference number/letter for each service. This will be a letter from A to L. All other verbiage that is on the current tutorial will remain the same. Enter the charge for each listed service 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: Competitive Acquisition Program (CAP) physicians should enter a billed amount for each CAP drug. Do not enter a zero dollar amount. Days or Units Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. 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, medication dosages, or allergy testing procedures). When multiple services are provided, enter the actual number provided. For anesthesia, show the elapsed time (minutes) in item 24G. Convert hours into minutes and enter the total minutes required for this procedure (e.g., 2 hours and 10 minutes would be reported as 130. One hour and 10 minutes would be reported as 70). For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of the Medicate Claims Processing Manual. ... Leave blank. Not required by Medicare. Entering information in this item may cause delays in claims processing. NOTE: Effective May 23, 2008, Item 24i is not to be reported. Effective May 23, 2008 Only an NPI may be entered in any provider identifier fields on claims submitted on or after May 23, 2008. Claims will be rejected when submitted with a Medicare legacy number (PIN/PTAN) or a UPIN in any provider identifying field on or after May 23, 2008. For more information, click within the field. 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. 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. 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. ... 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; each CMS-1500 Form should have its own total. 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; 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. Leave blank. Not required by Medicare. 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, 2006) the form was signed. In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31. ... 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 ... Effective May 23, 2008 Only an NPI may be entered in any provider identifier fields on claims submitted on or after May 23, 2008. Claims will be rejected when submitted with a Medicare legacy number (PIN/PTAN) or a UPIN in any provider identifying field on or after May 23, 2008. NOTE: Effective May 23, 2008, Item 32b is not to be reported. Provider's/ Supplier's Telephone Number, Billing Name, Address, and ZIP Code. This is a required field. Enter the provider of service/supplier's telephone number, billing name, address, and ZIP code. 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 Effective May 23, 2008 Only an NPI may be entered in any provider identifier fields on claims submitted on or after May 23, 2008. Claims will be rejected when submitted with a Medicare legacy number (PIN/PTAN) or a UPIN in any provider identifying field on or after May 23, 2008. For more information, click within the field. NOTE: Effective May 23, 2008, Item 33b is not to be reported.

Last Updated Dec 14, 2016