Claim Form Instructions
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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. For complete information CMS-1500 claim form versions 08/05 and 02/12, refer to: http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf
|MM||Month (e.g., December = 12)|
|DD||Day (e.g., Dec15 = 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 1|| |
Type of Health Insurance Coverage Applicable to the Claim
|Item 1a|| |
Insured's ID Number
|Item 2|| |
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
|Item 4|| |
|Item 5|| |
Patient's Address and Telephone Number
|Item 6|| |
Patient's Relationship to Insured
|Item 7|| |
Insurance Primary to Medicare, Insured's Address and Telephone Number
|Item 8|| |
Reserved for NUCC Use
|Item 9|| |
Medigap Benefits, Other Insured's Name
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 §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 A/B MAC 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
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
|Item 9c|| |
Reserved for NUCC Use
|Item 9d|| |
Medigap Benefits, Insurance Plan/Program Name, PAYERID Number
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. A Medicare participating provider or supplier shall only enter the COBA Medigap claimbased 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 §70.6.4 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. Noridian assigns five digit alpha numeric or numeric PAYERID numbers rather than nine digit numbers.
| Items |
Condition Relationship? Employment, Auto Liability, or Other Accident
|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. Leave blank. Not required by Noridian.
|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:
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
|Item 11b|| |
Insurance Primary to Medicare, Employer's Name
|Item 11c|| |
Insurance Plan/Program Name
|Item 11d|| |
Leave blank. Not required by Medicare.
|Item 12|| |
Patient's or Authorized Person's Signature
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
NOTE: This can be "Signature on File" and/or a computer generated signature.
|Item 14|| |
Date of Current Illness/Injury/Pregnancy
Additional information for form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in Item 14.
|Item 15|| |
Leave blank. Not required by Medicare.
|Item 16|| |
Dates Patient Unable to Work in Current Occupation
An entry in this field may indicate employment related insurance coverage.
|Item 17|| |
Name of the Referring or Ordering 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:
Enter the qualifier to the left of the dotted vertical line on Item 17.
NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to perform these roles. Refer to CMS IOM Publication 100-02, Medicare Benefits Policy Manual, Chapter 15 for non-physician practitioner rules. Enter non-physician practitioner information according to the rules above for physicians.
The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:
Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician's or non-physician practitioner's service.
The ordering/referring requirement became effective January 1, 1992, and is required by Section 1833(q) of the Social Security Act. All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See items 17a and 17b below for further guidance on reporting the referring/ordering provider's UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:
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.
|Item 17a|| |
Leave Blank. Not required by Medicare.
|Item 17b|| |
NPI of the Referring/Ordering Physician
|Item 18|| |
Service Furnished as a Result of, or Subsequent to, a Related Hospitalization
|Item 19|| |
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.
|Item 20|| |
Diagnostic and Purchased Tests
When billing for multiple purchased diagnostic tests, each test shall be submitted on a separate claim Form CMS- 1500. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different service facility locations. See chapter 1.
NOTE: This is a required field when billing for diagnostic tests subject to purchase price limitations.
|Item 21|| |
Enter the patient's diagnosis/condition to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.
Enter the indicator as a single digit between the vertical, dotted lines.
|Item 22|| |
Leave blank. Not required by Medicare
|Item 23|| |
Prior Authorization Number
|Item 24|| |
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
When billing a date span, it must be for consecutive days. If it is not, then bill each service separately. Days billed should correspond with the number of units in column G. If days span over a month, bill the services for each month on separate lines. Do not use quotation marks to indicate the date of service is the same as the line above. A date must be reported in this item.
|Item 24B|| |
Place of Service
NOTE: When a service is rendered to a hospital inpatient, use the "inpatient hospital" code.
Enter only one place of service code per CMS-1500 Form, unless second place of service code is 12 (patient's home).
|Item 24C|| |
Leave blank. Not required by Medicare.
|Item 24D|| |
Procedures, Services, or Supplies 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. Otherwise, an attachment must be submitted with the claim.
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.
Modifiers must be two alpha/numeric characters. Do not place extra narrative after, under, or above procedure code. Pricing modifiers should be placed in first modifier position. Procedure codes should not be placed in first modifier position. Be sure to distinguish between zeros and 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
|Item 24F|| |
Enter the charge for each listed service
NOTE: Competitive Acquisition Program (CAP) physicians should enter a billed amount for each CAP drug. Do not enter a zero dollar amount.
|Item 24G|| |
Days or Units
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.
Do not place zeros before or after 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 A/B Mac should program their system to automatically default "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|| |
|Item 24J|| |
PIN/NPI of the Rendering Provider
Enter the rendering provider's NPI number in the lower shaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion. An invalid NPI will cause the claim to be rejected as unprocessable.
Information must be submitted within confines of this box. Do not enter provider names or state postal codes in this item.
|Item 25|| |
Provider or Supplier Federal Tax ID (Employer Identification Number)
|Item 26|| |
Patient's Account Number
|Item 27|| |
The following providers of service/suppliers and claims can only be paid on an assignment basis:
|Item 28|| |
Total charges for services on claim
|Item 29|| |
Total amount the patient paid on the covered services only
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
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.
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.
|Item 32|| |
Name and Address of Facility Where Services Were Rendered
Enter name and address information in following format:
NOTE: Enter a complete address for location where the services were performed. A PO Box is not acceptable. Do not include telephone numbers, commas, periods, or other punctuation in address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between city and state postal code. When entering a 9-digit ZIP code, include hyphen.
Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier.
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.
For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC 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.
If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than the patient's home.
If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.
Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.
Ambulance suppliers are required to submit both origination and destination information. The originating site information must be entered in Item 32. It is recommended that providers list name of facility, city, state and ZIP code. The street address is not required. If there is not enough space for destination information in Item 32, providers must enter this information in Item 19. The origin and destination modifiers will identify type of facility beneficiary was transported to. When transport is beyond "closest facility", providers are required to briefly identify why and that information is also placed in item 19.
32. SERVICE FACILITY LOCATION INFORMATION
TO: Hospitals Inc
|Item 32a|| |
NPI of Service Facility
Providers of service (namely physicians) shall identify the supplier's NPI when billing for purchased diagnostic tests.
|Item 32b|| |
ID Qualifier and PIN
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 name and address information in following format:
|Item 33a|| |
NPI of Billing Provider or Group
|Item 33b|| |
ID Qualifier and PIN
NOTE: Effective May 23, 2008, Item 33b is not to be reported.
Last Updated Feb 26, 2018