The Centers for Medicare & Medicaid Services (CMS) 1500 health insurance claim form (updated as of 8/5) replaces what was formerly known as the Health Care Financing Administration (HCFA) 1500. The CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Medicare Parts A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs).
The CMS 1500 form is the cornerstone for billing physician and outpatient services and is something every medical billing and coding professional knows like the back of their hands. Tt is how reimbursement is made to a provider and supplier. Some of the common provider types who submit CMS 1500 forms are:
- Ambulatory Surgical Centers
- Certified Registered Nurse Anesthetists
- Chiropractic Care
- Community Mental Health
- Durable Medical Equipment (DME)
- Federally Qualified Health Centers
- Hearing Aid Providers
- Independent Laboratory
- Independent Radiology
- Mental Health Services
- Nurse Practitioners
- Optical/Vision Providers
- Physician Assistants
- Rural Health Clinics
- Therapy Services
Billing Tips for the CMS 1500 Form
A complete and separate claim form must be submitted for each patient. Each service must be represented on an individual claim line (line item) in order to be considered by the carrier for reimbursement.
For Electronic Submissions
- Use only black 10-point plain font without any effects such as italics, script, or stylized fonts
- Use only upper-case capital letters
- Do not use dollar signs, decimals, or punctuation
- Follow the correct Health Insurance Claim Number (HICN) format with no hyphens or dashes. The alpha prefix or suffix is part of the HICN and should not be omitted
- Make sure data is in the appropriate field and does not overlap into other fields
- Use an individual’s name in the provider signature field – not a facility or practice name
- Include all applicable NPIs (National Provider Identifier) on the claim. This includes the referring provider NPI
- Include special certification numbers for services such as clinical laboratory (CLIA number) or mammography (FDA number)
- Don’t use dashes 01- slashes in date fields
- Don’t use a dot matrix printer if possible
- Don’t use paper smaller or larger than 8 1/2x 11 – Scan equipment will accept 8 1/2 s 11 paper
- Print claim data within defined boxes on the claim form
- Use a laser printer for best results
- Print using Courier-10 pitch (12-point)
Special Note for Paper Claims (Certain carriers may require them for certain services.)
- Don’t use red ink or highlighters
- Don’t fold claim forms, appeals, or correspondence
- Don’t send duplicate copies of information
- Don’t staple, clip, or tape anything to the CMS 1500 form.
- Is free from tears, crumples, or excessive creases. Recommend submitting claims in a full letter size envelope
- Clean and free from stains, handwritten notations, circles or scribbles, strike-overs, crossed-out information or white out
- Do not print, hand-write, or stamp any extraneous data on the form
- Remove pin-fed edges at side perforations
- Use only lift-off correction tape to make corrections
- Use paper clips on claims or appeals if they include attachments
- Use the HHSC approved Medicare Remittance Advice Notice. or an MRAN printed from
- Place all necessary documentation in the envelope (Use 10×13 inch envelopes to mail claims), with the Form CMS-1500 claim form
- Photocopied claims are not accepted
- Claims that have been returned for correction/additional information must resubmit within the timely filing period, unless additional time has been allotted by the carrier
- Claims must be submitted within one year from the date of service
- Use current year-valid diagnosis codes and code them to the highest level of specificity (maximum number of digits) available
- Also make sure that the diagnosis codes used are appropriate for the gender and/or age of the patient
- Use current year-valid procedure codes as described in the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) manuals
- Use only Level II HCPCS codes, not local codes
- Use current valid modifiers when necessary
- If a paper claim is required for a service from a carrier, make sure that the correct date of service (DOS) is submitted with that claim
Key Points for CMS 1500 Form Submission: The CMS 1500 Form Has 33 Fields
• 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
BLOCK 1A INSURED’S I.D. NUMBER (For Program in Block 1)
• Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
BLOCK 2 PATIENT’S NAME
• Enter the patient’s last name, first name, and middle initial, if any, exactly as shown on the patient’s Medicare card.
BLOCK 3 PATIENT’S BIRTH DATE AND SEX
• Enter the patient’s birth date (MMDDCCYY) and sex.
BLOCK 4 INSURED’S NAME
• 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”. If there is no insurance primary to Medicare, leave blank.
BLOCK 5 PATIENT’S ADDRESS
• 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. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.
BLOCK 6 PATIENT RELATIONSHIP TO INSURED
• Check the appropriate box for patient’s relationship to the insured when block 4 is completed.
BLOCK 7 INSURED’S ADDRESS
• Enter the insured’s address and telephone number. When the address is the same as the patient’s, enter the word SAME. Complete this block only when blocks 4 and 11 are completed.
BLOCK 8 PATIENT STATUS
• Check the appropriate box for the patient’s marital status and whether employed or a student.
CMS BOX BLOCK 9 OTHER INSURED’S NAME
• Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word “SAME”. If no Medigap benefits are assigned, leave blank.
BLOCK 9A OTHER INSURED’S POLICY OR GROUP NUMBER
• Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.
BLOCK 9B OTHER INSURED’S DATE OF BIRTH
• Enter the Medigap enrollee’s birth date (MMDDCCYY) and sex.
BLOCK 9C EMPLOYER’S NAME OR SCHOOL NAME
• Disregard “employer’s name or school name” which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured’s Medigap identification card. Note: If a carrier assigned unique identifier of a Medigap insurer appears in block 9D, block 9C may be left blank.
BLOCK 9D INSURANCE PLAN NAME OR PROGRAM NAME
• Enter the name of the Medigap insured’s insurance company or the Medigap insurer’s unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in block 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.
BLOCK 10A THROUGH 10C IS PATIENT’S CONDITION RELATED TO:
• Check “YES” or “NO” to indicate whether employment, auto accident or other accident (i.e., liability suit) involvement applies to one or more of the services described in block 24. Enter the state postal code. Any item checked “YES” indicates there may be other insurance primary to Medicare. Identify primary insurance information in block 11.
BLOCK 10D RESERVED FOR LOCAL USE
• Use this block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by “MCD”.
BLOCK 11 INSURED’S POLICY, GROUP OR FECA NUMBER
• When submitting paper or electronic claims, block 11 must be completed. By completing this information, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.
• Note: If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to blocks 11a-11c. If there is no insurance primary to Medicare, enter the word “NONE” in block 11 and proceed to block 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 block 11b.
BLOCK 11A INSURED’S DATE OF BIRTH
• Enter the insured’s birth date (MMDDCCYY) and sex, if different from block 3.
BLOCK 11B EMPLOYER’S NAME OR SCHOOL NAME
• Enter the employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the six – digit retirement date (MMDDYY) preceded by the word “RETIRED.”
BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME
• Enter the complete insurance plan or program name, e.g., Blue Shield of (State). 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.
BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN
• Leave blank if submitting to Medicare.
CMS 1500 – BLOCK 12 PATIENT OR AUTHORIZED PERSON’S SIGNATURE
• Paper Claims: The patient or an authorized representative must sign and enter the six – digit date (MMDDYY) for this block unless the signature is on file – Electronic Claims. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative 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 form. The signature on file authorization is effective indefinitely unless patient or the patient’s representative revokes the arrangement.
• Signature on File Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary’s behalf.
BLOCK 13 INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
• The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization.
• The Medigap assignment on file in the participating physician/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
BLOCK 14 DATE OF CURRENT ILLNESS
• Enter the six – digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six – digit date (MMDDYY) of the initiation of the course of treatment
BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS – *Not required by Medicare.
BLOCK 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
• Enter the six – digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage. Completion of this field is conditional for disability information.
BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
• Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
• Enter the six – digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
BLOCK 19 RESERVED FOR LOCAL USE
BLOCK 20 OUTSIDE LAB
• Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the “YES” block is checked. A “YES” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “NO” check indicates that “no purchased tests are included on the claim”. When “YES” is annotated, block 32 must be completed.
BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
• Enter the patient’s diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.
BLOCK 22 MEDICAID RESUBMISSION – *Not required by Medicare.
BLOCK 23 PRIOR AUTHORIZATION NUMBER
• Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
• Enter the Investigational Device Exemption (IDE) number for those clinical trial procedures requiring IDE approval.
• For paper claims only, enter the ten – digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.
CMS 1500 – BLOCK 24A DATES OF SERVICE
• Enter the six or eight – digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.
BLOCK 24B PLACE OF SERVICE
• Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed.
BLOCK 24C TYPE OF SERVICE – *Not required by Medicare
BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES
• Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the 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.
BLOCK 24E DIAGNOSIS CODE
• Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21.
BLOCK 24F ($) CHARGES
• Enter the charge for each listed service.
BLOCK 24G 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.
BLOCK 24H EPSDT FAMILY PLANNING – *Not required by Medicare.
BLOCK 24I EMG – *Not required by Medicare.
BLOCK 24J COB – *Not required by Medicare.
BLOCK 24K RESERVED FOR LOCAL USE
• Enter the carrier assigned Provider Identification Number (PIN) and NPI number of the rendering physician.
BLOCK 25 FEDERAL TAX ID NUMBER
• Enter your provider of service and (or) supplier Federal Tax Employer Identification Number (EIN) or Social Security Number. The participating provider of service and (or) supplier federal tax identification number is required for a mandated Medigap transfer.
BLOCK 26 PATIENT’S ACCOUNT NUMBER
• Enter the patient’s account number assigned by the provider of service and (or) supplier’s accounting system. This is an optional field to enhance patient information.
BLOCK 27 ACCEPT ASSIGNMENT
• Check the appropriate block to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in block 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.
BLOCK 28 TOTAL CHARGE
• Enter the total charges of all services reported on the claim (i.e., total of all charges from block 24f). Completion of this field is required for all claims.
BLOCK 29 AMOUNT PAID
• Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges. Completion of this field (i.e., amount paid or “$0.00″) is required for all claims.
BLOCK 30 BALANCE DUE – *Not required by Medicare.
BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED
• Enter the name and address including the ZIP code of the facility where the services were furnished. When the name and address of the facility where the services were furnished is the same as the biller’s name and address shown in block 33, enter the word “SAME”.
BLOCK 33 PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
• Enter the physician’s individual/group or or supplier’s billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.
• Enter the carrier assigned PIN# and NPI for the performing physician or supplier who is not a member of a group practice.
• Enter the carrier assigned GRP# and NPI for the group. Complete either the PIN# or GRP# field, not both. Completion of this field is required for all claims.
• For more information on how to complete a CMS 1500 form from Medicare, please click here
• For a virtual look at a complete CMS 1500 from Ladies First Providers Vermont, please click here.
Having a thorough understanding of what fields require information for successful claims submission to a carrier is paramount to submitting a “Clean Claim”. Ensuring that the correct information is on the form will reduce denials, reduce the number of days a claim sits on your Accounts Receivable (AR) report and will increase timely receipt of reimbursement to the practice.
Test Your Knowledge
Last Week’s Quizlet:
Question: Explain the difference between a CPT code and an ICD-9-CM code
• CPT 4 codes are used to report medical procedures performed by doctors and other Non-Physician Practitioners(NPPs).
• ICD-9-CM diagnosis codes are used to report the symptoms and conditions that a patient may be experiencing at the time of the doctors’ visit
Test Your Knowledge
1. What was the former name of the CMS 1500?
2. When was the name changed?
You can find the answers to this weeks Quizlet in next Mondays edition of Connect Mondays – Medical Billing 101