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.
| 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.
|
| 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:
|
| 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 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 .
