What information is entered into Item 1 of the CMS 1500?

This billing guide is designed to assist with the completion of the CMS-1500 claim form. Submit only the red drop out approved CMS-1500 (02-12) claim form.

1500 Health Insurance Claim Form Reference Instruction Manual V.02/12 - Updated July 2021.

Billing Guide for HCFA-1500 (CMS-1500) Claim Form

Follow these tips to help ensure proper scanning and timely processing:

• Enter the data within the boundaries of the fields provided and ensure all information is aligned properly. Do not write between lines.
• Type (in Arial or Times New Roman font) or print all information. Entries should be dark enough to be legible.
• Use black ink only. Red and blue ink cannot be properly "read" by the scanning equipment.
• Do not highlight the claim form or attachments. Highlighted information can become “blackedout” when scanned.
• Do not submit claim forms with corrections, such as information written over correction fluid or crossed out information. If mistakes are made, complete a new form.
• Capitalize alpha characters. Do not use special characters (e.g., dollar signs, decimals, dashes). Do not use commas to separate thousands.
• Do not write or use staples on the bar-code area.
• Do not use adhesive labels (e.g., address) or place stickers on the form. Do not use a rubber stamp in any fields on the form.

KEY:
R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim

Field IDField DescriptionData TypeInstructions1TYPE OF HEALTH INSURANCE COVERAGERShow 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).1AINSURED ID NUMBERRList the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.2PATIENT’S NAMEREnter the patient's last name, first name, and middle initial, if any. NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.3PATIENT’S BIRTH DATE/GENDERREnter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.4INSURED’S NAMEREnter the insured's full last name, first name and middle initial. If the insured has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name.5PATIENT’S ADDRESS/TELEPHONE NUMBERREnter 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 phone number.6PATIENT’S RELATIONSHIP TO THE INSUREDRSelect the appropriate box for patient’s relationship to the insured person.7INSURED’S ADDRESS/TELEPHONE NUMBERSEnter the insured person’s permanent mailing address (complete if different from the patient’s address)8RESERVED FOR NUCC USENRCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.9OTHER INSURED’S NAMESCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.9aOTHER INSURED’S POLICY OR GROUP NUMBERSCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.9bRESERVED FOR NUCC USENRCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.9cRESERVED FOR NUCC USENRCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.9dINSURANCE PLAN NAME OR PROGRAM NAMENRCheck the appropriate box for the patient's relationship to the insured when item 4 is completed.10
a - cIS PATIENT’S CONDITION RELATED TO: 

For 10a – 10c, required status is contingent upon a definitive “Yes” or “No” answer. If you are unsure, leave blank. Check "YES" or "NO" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in item 24. The state postal code, (i.e. MO) must be shown. Any item checked "YES" indicates there may be other insurance primary to Medicare. Primary insurance information must then be shown in item 11.

If you are unsure, leave blank.

10a SSelect whether the patient’s condition is related to employment.10b SSelect whether the patient’s condition is related to an auto accident and enter the state in which the accident occurred. Use two-character abbreviation.10c SSelect whether the patient’s condition is related to any other type of accident.10dCLAIM CODES (DESIGNATED BY NUCC)S(11 thru 11d, refer to subscriber coverage)11INSURED’S POLICY GROUP OR FECA NUMBERNREnter the subscriber’s group number.11aINSURED’S DATE OF BIRTH, GENDERNREnter the subscriber’s date of birth using the eight-digit date format (MM/DD/CCYY) and
select the subscriber’s gender.11bOTHER CLAIM ID (DESIGNATED BY NUCC)NR.11cINSURANCE PLAN NAME OR PROGRAM NAMENREnter the subscriber’s insurance plan name, include name of state.11dIS THERE ANOTHER HEALTH INSURANCE BENEFIT PLAN?RSelect whether there is another health insurance plan. Remember, if there is another health insurance plan, you will need to complete fields 9, 9a, and 9d. This information is necessary to coordinate benefits with other insurance companies.12PATIENT OR AUTHORIZED PERSON’S SIGNATURER

Enter the phrase SIGNATURE ON FILE, or include legal signature (and date) of patient or authorized person.

In lieu of signing the claim, the patient must sign a statement to be retained in the provider, physician, or supplier’s file in accordance with Chapter 1 "General Billing Requirements". If the patient is physically or mentally unable to sign, a representative specified in 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.For date fields other than date of birth, all fields must be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

13INSURED OR AUTHORIZED PERSON’S SIGNATURER

Enter the phrase SIGNATURE ON FILE, or include legal signature (and date) of patient or authorized person. If neither, leave blank or state no signature on file.

The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if the required Medigap information is included in ltem 9 and its subdivisions. The patient or his or her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization (See Signature on File beginning on p. 3.S.1.) 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.

Note: This can be "Signature on File" and/or a computer generated signature.For date fields other than date of birth, all fields must be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

14DATE OF CURRENT ILLNESS, INJURY, OR PREGNANCY (LMP)SEnter the date using an eight-digit date format (MM/DD/CCYY).15OTHER DATESEnter the date using an eight-digit date format (MM/DD/CCYY). Need qualifier, See NUCC manual.16DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATIONSEnter the date using an eight-digit date format (MM/DD/CCYY).17NAME OF REFERRING PROVIDER OR OTHER SOURCER

NOTE: Field required for Ancillary Claims.

Enter the referring, ordering or supervising provider’s first name, middle initial, last name and credentials. This field is required only if there is a referring, ordering or supervising provider.

17aOTHER ID#NRNot required, reserved for taxonomy code (preceded by “ZZ” qualifier).17bNPI#REnter the 10-digit NPI number of the referring, ordering or supervising provider.18HOSPITAL DATES RELATED TO CURRENT SERVICESSEnter the hospital dates using an eight-digit date format (MM/DD/CCYY).19ADDITIONAL CLAIM INFORMATION (DESIGNATED BY NUCC)NRReserved 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.

20OUTSIDE LAB/CHARGESRSelect “Yes” or “No” to indicate if the claim includes charges for lab services performed outside of the physician’s office. If Yes,” enter the total charges. 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.21DIAGNOSIS OR NATURE OF ILLNESS OR INJURYREnter the ICD- CM codes. The primary diagnosis should be entered first, followed by other
diagnoses if applicable. Up to 11 additional ICD-CM codes can be entered. ICS Ind. Required.22RESUBMISSIONNRMedicaid Resubmission Code23PRIOR AUTHORIZATION NUMBERNRIf applicable, enter prior authorization or referral number.24SHADED AREA – SUPPLEMENTAL INFORMATION The shaded area of field 24a - 24h was created to accommodate supplemental information. For more information, see the National Uniform Claim Committee’s Web site at www.nucc.org.24aDATE(S) OF SERVICEREnter the dates of service using an eight-digit date format (MM/DD/CCYY). Cannot be a future date.24bPLACE OF SERVICEREnter the appropriate two-digit Place of Service code.24cEMGSIf this service was an emergency, enter “Y” for “Yes,” or leave blank if “No.”24dPROCEDURES, SERVICES, OR SUPPLIESREnter the CPT or HCPCS code for the procedures, services or supplies, and enter a modifier if applicable.24eDIAGNOSIS POINTERREnter the appropriate ICD- CM diagnosis code or codes for each procedure performed. Enter one code per line of service. Not - Use alpha (A-L), not numeric24fCHARGESREnter the charge for each line of service. Do NOT include discounts/negative amounts.24gDAYS or UNITSREnter the number of days or units for each line of service.24hEPSDT/FAMILY PLANSIf applicable, enter the appropriate Early and Periodic Screening, Diagnosis and Treatment (EPSDT) code or family planning (FP) code.24iID QUALIFIER - SHADED FIELDRReserved for taxonomy code qualifier, “ZZ ”24jRENDERING PROVIDER I.D. #RReserved for taxonomy code. Note: Required for Group Practices.24kNON-SHADED FIELDREnter the performing provider’s 10-digit NPI number in the non-shaded area.25FEDERAL TAX I.D. NUMBERREnter the Federal Tax I.D. Number for the provider of service. Select the appropriate field for SSN or EIN.26PATIENT ACCOUNT NUMBERSEnter account number assigned to the patient, if applicable. This field is optional to assist the provider in patient identification. As a service, any account numbers entered here will be returned to the provider.27ACCEPT ASSIGNMENTR

Select "Yes." Note: Only if the provider participates with Medicare Universal Healthcare.

The following providers of service/suppliers and claims can only be paid on an assignment basis:

• 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.

28TOTAL CHARGEREnter the total charge for all services (total of all charges in 24f).
Note: If multiple pages, put total on last page only.29AMOUNT PAIDSEnter the amount paid by the patient or other payers on covered services only.30RESERVED FOR NUCC USENR 31SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDE DEGREES OR CREDENTIALSRThe claim must be signed by the physician/supplier or an authorized representative. The form must also be dated, using an eight-digit date format (MM/DD/CCYY). Should match rendering provider signature - field 24J32SERVICE FACILITY LOCATION INFORMATIONR

Enter the location where the services were rendered. The provider of service must identify the
supplier’s information when billing for purchased diagnostic tests.

Note: Required when different from Billing Provider. Per the NUCC Instruction Manual, Field 32 is required if Field 20 is checked “yes.”

For more information, see the National Uniform Claim Committee’s Web site at www.nucc.org.

32aNPISEnter the 10-digit NPI number of the service facility location.32bOTHER ID#SReserved for taxonomy code - including ZZ qualifier.33BILLING PROVIDER INFO AND PH#REnter the information of the billing provider or supplier to be paid for services.
Note: Provide physical address in this field33aNPIREnter the 10-digit NPI number of the billing provider.33bOTHER ID#RReserved for taxonomy code - including ZZ qualifier.
Note: Required for Individual/Solo Practices.

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Place of Service Codes

CODESDEFINITIONS01Pharmacy  03School04Homeless Shelter05Indian Health Service Free-standing Facility06Indian Health Service Provider-based Facility07Tribal 638 Free-standing Facility08Tribal 638 Provider-standing Facility09Prison Correctional Facility  11Office12Home13Assisted Living Facility14Group Home15Mobile Unit16Temporary Lodging  20Urgent Care Facility21Inpatient Hospital22Outpatient Hospital23Emergency Room Hospital24Ambulatory Surgical Center25Birthing Center26Military Treatment Facility  31Skilled Nurse Facility32Nursing Facility33Custodial Care Facility34Hospice  41Ambulance (Land)42Ambulance (Air or water)  49Independent Clinic50Federally Qualified Health Center51Inpatient Psychiatric Facility52Psychiatric Facility Partial Hospitalization53Community Mental Health Center54Intermediate Care Facility/Mentally Retarded55Residential Substance Abuse Treatment Center56Psychiatric Residential Treatment Center57Non-residential Substance Abuse Treatment Facility  60Mass Immunization Center61Comprehensive Inpatient Rehabilitation Facility62Comprehensive Outpatient Rehabilitation Facility  65End-Stage Renal Disease Treatment Facility  71Public Health Clinic72Rural Health Clinic  81Independent Laboratory  99Other place of service

Instructions and Examples of Supplemental Information in Item Number 24

The following are types of supplemental information that can be entered in the shaded lines of Item Number 24:

• Anesthesia duration in hours and/or minutes with start and end times
• Narrative description of unspecified codes
• National Drug Codes (NDC) for drugs
• Vendor Product Number – Health Industry Business Communications Council (HIBCC)
• Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN), formerly Universal Product Code (UPC) for products
• Contract rate

The following qualifiers are to be used when reporting these services.

• 7 - Anesthesia information
• ZZ - Narrative description of unspecified code
• N4 - National Drug Codes (NDC)
• VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard
• OZ - Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN)
• CTR - Contract rate

For additional information for reporting NDC units, see the National Uniform Claim Committee’s website at www.nucc.org.

REMINDERS

Complete all required fields. Make certain to enter the following identifying information:

• Put the insured’s prefix and identification number in Field 1a.
• Put the physician or supplier’s billing name, address, zip code, telephone number and NPI number in Field 33

The information required to file electronic claims is the same as for paper claims but there are major advantages to submitting electronic claims versus paper claims:

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