Tips for Completing the HCFA-1500 (CMS1500) Form

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.

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 ID Field Description Data Type Instructions
1 TYPE OF HEALTH INSURANCE COVERAGE R 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).
1A INSURED ID NUMBER R List 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.
2 PATIENT’S NAME R Enter 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.
3 PATIENT’S BIRTH DATE/GENDER R Enter 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.
4 INSURED’S NAME R Enter 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.
5 PATIENT’S ADDRESS/TELEPHONE NUMBER R 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 phone number.
6 PATIENT’S RELATIONSHIP TO THE INSURED R Select the appropriate box for patient’s relationship to the insured person.
7 INSURED’S ADDRESS/TELEPHONE NUMBER S Enter the insured person’s permanent mailing address (complete if different from the patient’s address)
8 RESERVED FOR NUCC USE NR Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
9 OTHER INSURED’S NAME S Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
9a OTHER INSURED’S POLICY OR GROUP NUMBER S Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
9b RESERVED FOR NUCC USE NR Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
9c RESERVED FOR NUCC USE NR Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
9d INSURANCE PLAN NAME OR PROGRAM NAME NR Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
10
a - c
IS 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   S Select whether the patient’s condition is related to employment.
10b   S Select 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   S Select whether the patient’s condition is related to any other type of accident.
10d CLAIM CODES (DESIGNATED BY NUCC) S (11 thru 11d, refer to subscriber coverage)
11 INSURED’S POLICY GROUP OR FECA NUMBER NR Enter the subscriber’s group number.
11a INSURED’S DATE OF BIRTH, GENDER NR Enter the subscriber’s date of birth using the eight-digit date format (MM/DD/CCYY) and
select the subscriber’s gender.
11b OTHER CLAIM ID (DESIGNATED BY NUCC) NR .
11c INSURANCE PLAN NAME OR PROGRAM NAME NR Enter the subscriber’s insurance plan name, include name of state.
11d IS THERE ANOTHER HEALTH INSURANCE BENEFIT PLAN? R Select 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.
12 PATIENT OR AUTHORIZED PERSON’S SIGNATURE R

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.

13 INSURED OR AUTHORIZED PERSON’S SIGNATURE R

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.

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

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.

17a OTHER ID# NR Not required, reserved for taxonomy code (preceded by “ZZ” qualifier).
17b NPI# R Enter the 10-digit NPI number of the referring, ordering or supervising provider.
18 HOSPITAL DATES RELATED TO CURRENT SERVICES S Enter the hospital dates using an eight-digit date format (MM/DD/CCYY).
19 ADDITIONAL CLAIM INFORMATION (DESIGNATED BY NUCC) NR 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.
20 OUTSIDE LAB/CHARGES R Select “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.
21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY R Enter 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.
22 RESUBMISSION NR Medicaid Resubmission Code
23 PRIOR AUTHORIZATION NUMBER NR If applicable, enter prior authorization or referral number.
24 SHADED 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.
24a DATE(S) OF SERVICE R Enter the dates of service using an eight-digit date format (MM/DD/CCYY). Cannot be a future date.
24b PLACE OF SERVICE R Enter the appropriate two-digit Place of Service code.
24c EMG S If this service was an emergency, enter “Y” for “Yes,” or leave blank if “No.”
24d PROCEDURES, SERVICES, OR SUPPLIES R Enter the CPT or HCPCS code for the procedures, services or supplies, and enter a modifier if applicable.
24e DIAGNOSIS POINTER R Enter 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 numeric
24f CHARGES R Enter the charge for each line of service. Do NOT include discounts/negative amounts.
24g DAYS or UNITS R Enter the number of days or units for each line of service.
24h EPSDT/FAMILY PLAN S If applicable, enter the appropriate Early and Periodic Screening, Diagnosis and Treatment (EPSDT) code or family planning (FP) code.
24i ID QUALIFIER - SHADED FIELD R Reserved for taxonomy code qualifier, “ZZ ”
24j RENDERING PROVIDER I.D. # R Reserved for taxonomy code. Note: Required for Group Practices.
24k NON-SHADED FIELD R Enter the performing provider’s 10-digit NPI number in the non-shaded area.
25 FEDERAL TAX I.D. NUMBER R Enter the Federal Tax I.D. Number for the provider of service. Select the appropriate field for SSN or EIN.
26 PATIENT ACCOUNT NUMBER S Enter 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.
27 ACCEPT ASSIGNMENT R

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.
28 TOTAL CHARGE R Enter the total charge for all services (total of all charges in 24f).
Note: If multiple pages, put total on last page only.
29 AMOUNT PAID S Enter the amount paid by the patient or other payers on covered services only.
30 RESERVED FOR NUCC USE NR  
31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDE DEGREES OR CREDENTIALS R The 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 24J
32 SERVICE FACILITY LOCATION INFORMATION R

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.

32a NPI S Enter the 10-digit NPI number of the service facility location.
32b OTHER ID# S Reserved for taxonomy code - including ZZ qualifier.
33 BILLING PROVIDER INFO AND PH# R Enter the information of the billing provider or supplier to be paid for services.
Note: Provide physical address in this field
33a NPI R Enter the 10-digit NPI number of the billing provider.
33b OTHER ID# R Reserved for taxonomy code - including ZZ qualifier.
Note: Required for Individual/Solo Practices.

Place of Service Codes

CODES DEFINITIONS
01 Pharmacy
   
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-standing Facility
09 Prison Correctional Facility
   
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
   
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
   
31 Skilled Nurse Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
   
41 Ambulance (Land)
42 Ambulance (Air or water)
   
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Center
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
   
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
   
65 End-Stage Renal Disease Treatment Facility
   
71 Public Health Clinic
72 Rural Health Clinic
   
81 Independent Laboratory
   
99 Other 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:

  • You will reduce your overhead, electronically submitted claims can save hours of clerical time.
  • You have better control and accuracy.
  • You know when your claims are received because your office receives special reports detailing which claims were accepted. If there is a problem with your claim, you can correct it before the claim is processed.

For additional information on Place of Service Codes, please visit The Official CMS Website .

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