The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.
The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form
Field by Field Explanation of the CMS-1500/HCFA 1500 Form
A CMS-1500 form contains 33 boxes. All of these items must be checked in order for the insurance claim to be processed. Let's go through all of the boxes or fields one by one.
BOXES “2, 3, 5 & 6” are for the Patient identification
Box 2: It is a required field. Fill in the patient's name as it appears on the ID card. Enter the patient's full name, first name, and middle initial, if any, as it appears on the patient's ID card.
Box 3: It is where the patient's 8-digit birth date (MM/DD/YYYY) must be entered. It also contains one box that must be ticked to indicate the patient's gender.
Box 5: This box requires you to enter the patient’s address & phone number. Patient address including , area, state, ZIP code.
Box 6: You must enter the patient's relation with the insured in this box.
BOXES “1, 1A, 4, 7, & 11” are for Patient's Insurance Coverage
BOX 1: It's optional. You must enter the type of insurance here. You would have options like Medicare, Medicaid, TRICARE, CHAMPVA, FECA, Black Lung, Public Health Insurance, etc. in the form. For instance, you would need to select the Medicare checkbox if you had submitted a Medicare claim.
BOX 1A: Insured’s ID Number – This box requires the ID of the patient.
Box 4 (if applicable): Insured’s name is required to be entered here. It won’t be required unless the patient and subscriber is Different.
Box 7: This box requires you to enter the insured’s address & phone number. Patient address including , area, state, ZIP code.
Box 11: The policy or group number for the insured must be entered in this field.
BOX “21” is for the Diagnosis Codes
Box 21: The patient's diagnosis or type of illness must be described in detail in this box. Diagnosis or Nature of Illness or Injury - Enter the full ICD-9-CM code, including the fourth and fifth digits if applicable, for each diagnosis.
Box 23 - is for Prior Authorization / referral Number - Enter prior authorization or referral number.
BOX “24A” is for Date of Service
Box 24A: Dates of Service - In the "from" and "to" boxes, use the MMDDYY format to enter the date the service was provided. Only the "from" column will list services that were rendered on a single date. If the services (such as DME rental, hemodialysis management, radiation therapy, etc.) were rendered over a number of dates, the range of dates and total number of services should be stated. Never let the "To" date exceed the day the Health Plan receives the claim.
BOXES “24D & 24G” are for CPT Codes & Units
Box 24D: Procedures, Services, or Supplies - Enter the relevant CPT and/or HCPCS National codes in this section. When applicable, modifiers are listed under the "modifier" column to the right of the primary code. If the item is a medical supply, enter the two-digit manufacturer code in the modifier field following the five-digit medical supply code.
Box 24G: Days or Units - Indicate the number of doctor visits or procedures, oxygen consumption, anesthesia time units, and other factors. No leading zeros or decimal points should be used. Leave no space empty because there should be at least 1 unit.
BOX “24F” is for the Charges
Box 24F: Charges - Enter the charge for service in dollar amount format.
BOX “24J” is for the provider who rendered service
Rendering Provider ID #/ NPI - Enter the Rendering Provider's NPI number
BOXES “24B and 32 ” are for the Place Code & Service Facility
Box 24B: You must enter the location where the service was provided in this field. The appropriate two-digit place of service code, as listed in Place of Service Codes for Professional Claims, must be entered.
Box 32: Name and address of the facility where services were provided must be entered into this field. You would have to enter the facility's NPI.
BOX 26 Patient's Account Number -Enter the patient’s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated.
BOX “33” is for the Billing provider
Box 33: Billing Provider Info & Phone # (Pay-To) - Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number.
Box 33A: You need to enter the NPI of the Billing provider.
BOX 33B: Billing Provider Info & Phone # (Pay-To) - Used for a typical providers only. Enter the Medi-Cal provider number for the billing provider
Other Required Boxes/Fields
Box 11D - Is there another health benefit plan? Check Yes or No
Box 14 - Date of Current - Illness (First Symptom) OR Injury OR Pregnancy (LMP) - Enter the date of onset of the member's illness, the date of accident/injury or the date of the last menstrual period.
Box 24 E - Diagnosis Pointer - Enter the diagnosis code number from box 21 that applies to the procedure code indicated in 24D
Box 25 - Federal Tax ID Number - Enter the Federal Tax ID for the billing provider.
Box 28 - Total Charge -Enter the total for all services in dollar and cents. Do not include decimals. Do not leave blank.
Box 29 - Amount Paid - Enter the amount of payment received from the Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals
Box 31 - Signature of Physician or Supplier Including Degrees or Credentials -The claims must be signed and dated by the provider or a representative assigned by the provider in black pen. An original signature is required.
Other Fields Non Mandatory / If Applicable need to update
Box 8 - Patient Status
Box 9 - Other Insured's Information - Name, Policy/Group Number, Employer/School Name, Insurance Plan/Program Name
Box 10 a-c Patient's Condition Relation
Box 10 D - Reserved For Local Use
Box 11 a-b - Insured's Information - Name, Policy/Group Number, Employer/School Name, Insurance Plan/Program Name
Box 12 - Signature and Date
Box 13 - Insured's or Authorized Person's Signature
Box 15 - If patient had same or similar illness give first date
Box 16 - Dates Patient Unable to Work in Current Occupation
Box 17 - Name of Referring Provider or Other Source - Enter the full name of the Referring Provider. A referring/ordering provider is one who requests services for a member, such as provider consultation, diagnostic laboratory or radiological tests, physical or other therapies, pharmaceuticals or durable medical equipment.
Box 18 - Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank.
Box 19 - Reserved for Local Use - Use this area for procedures that require additional information, justification or an Emergency Certification Statement.
• This section may be used for an unlisted procedure code when explanation is required and clinical review is required.
• If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be
listed.
• Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits.
• All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.
• Anesthesia start and stop times.
• Itemization of miscellaneous supplies, etc.
Box 20 - Outside Lab? - Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside
Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory
Box 22 - Medicaid Resubmission Code
Box 27 - Accept Assignment?
Box 30 - Balance Due - Enter the difference between the Total Charges and the Amount Paid in full dollar amount and cents. Do not enter decimals
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