How to Determine the Information Required to Correctly Complete the CMS 1500

The CMS 1500 is an insurance claim submission form used by medical facilities to submit paper claims to a third-party payer for payment. The third-party payer generally refers to the insurance company, or in the case of Medicare and Medicaid, the government. This form is filled out by the medical biller or coder after the patient has seen the physician and has been diagnosed for symptoms from that visit. Once the form has been correctly completed, it is submitted for reimbursement. Submitting correct claims is important for the flow of payments of the medical facility.

Things You'll Need

• CMS 1500 form
• Medical chart
• Patient's personal information

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Instructions

• 1

  Fill out Section 1 with the appropriate patient information. In boxes for items 1 and 1a, check the box to identify the patient's type of insurance and write in the insurance ID number. Items 2 to 8 are to be filled in with the patient's personal information such as name, address, birth date, etc.

• 2

  Complete items 9a to 9d with the patient's insurance information. Item 10 has boxes asking if the patient's condition is related to work or some kind of accident. Check boxes here where appropriate, according to the physician notes in the patient's chart.

• 3

  Fill in item 11 with secondary insurance information if the patient has secondary insurance. On the signature line in item 12, the form requests the patient's signature. Since the patient is usually not present at the time of billing, the biller is required to note that the patient's signature is "on file" and note the date when this signature was obtained. The signature for item 13 only needs to be present or on file if the patient has a secondary insurance program.

• 4

  Fill in item 14 of Section 2 with the date the first symptoms manifested. This date will be in the medical chart. Lines 15 and 16 are for dates of similar illnesses and dates the patient may have been unable to work.

• 5

  Enter the referring physician's name in item 17, if there is one stated. Then, in 17a and 17b, fill in the referring provider's identification number and national provider identification. Fill in item 18 with dates of hospitalization related to the current injury or illness, if applicable. Do not fill in line 19. This is reserved for local use only.

• 6

  List any outside diagnostic services in item 20. Enter diagnosis codes from the patient's encounter form into item 21. A maximum of eight diagnosis codes can be listed. Item 22 is only to be filled in when resubmitting a claim to Medicaid. If the patient's insurance company required prior authorization before a procedure, enter the prior authorization number in box 23.

• 7

  Enter the dates of service for the office visit or procedure in line 24a. Line 24b is where the place of service code should be marked. For example, if the patient was seen in the physician's office, the place of service code would be 11. Place of service codes are listed in the front of the Current Procedural Terminology (CPT) code book. Line 24c is only to be filled out if the patient received procedures or services in a department of a hospital.

• 8

  Enter the CPT procedure codes for the visit on line 24d. This includes any services or supplies that are used. Item 24e is called a "diagnosis pointer." This is for the reference of the diagnosis code the procedure or service was for. Fill in the number of days or units in item 24g. Item 24h identifies a family plan.

• 9

  Fill in item 24i with the Identification Qualifier for the referring provider. This refers to the provider's service number given to him by his insurance company, or the state licensing number. Item 24j is for the rendering provider's NPI number. Fill in the tax identification number in line 25.

• 10

  Complete line 26 with the patient's account number. Check the box next to "Accept assignment." This means the provider agrees to the insurance company's reimbursement guidelines. Enter total charge on line 28, amount paid on line 29, and balance due on line 30.

• 11

  Place the signature of the provider (physician) on line 31. Fill in the physician's address on line 32. Line 32a is for the service facility's location. Any other identification numbers should be listed in 32b. Item 33 is filled in with the physician's billing name, address and phone number. Enter the NPI of the service location in 33a, and any other identification numbers on line 33b.

• 12

  Review the CMS form completely. Make sure that all fields are filled in with the appropriate requested information. Submit the claim for reimbursement.