Instructions for Completing CMS 1500 Claim Forms in North Carolina

The Centers for Medicare and Medicaid Services (CMS) Form 1500 is a medical claims form used by medical providers and suppliers to bill a Medicaid carrier. The National Uniform Claim Committee (NUCC) is in charge of updating and maintaining the form, which has been modified many times as needed. The most recent update, as of 2010, was the implementation of the National Provider Identifier Number.

The CMS 1500 Form is sold at printers and local office supply stores. The U.S. Government Print Office supplies them as well and can be contacted by calling 1-866-512-1800.

Instructions

• 1

  Enter the insurance carrier's name and address in the carrier block located in the upper left-hand corner. Leave the second address line blank if you only need one line for the street address and one line for the city, state and zip. Abbreviate the state name.

• 2

  Mark the patient's insurance carrier with an "X".

• 3

  Provide the patient's insurance identification number. Use an employee I.D. if this is a worker's compensation claim and the patient's social security or tax identification number if this is an other property and casualty claim.

• 4

  Enter the patient's last name, first name and middle initial. Separate each by commas. Provide the date of birth as: MM/DD/YYYY and mark the patient's gender with an "X".

• 5

  Enter the name of the insured party, if different from the patient. For example, use the employer's last, first and middle name in a worker's compensation case.

• 6

  Provide the address of the patient and the patient's relationship to the insured. Indicate "self" if the patient is the person with insurance.

• 7

  Indicate the patient's marital and employment status. If patient has additional insurance, fill out section 9 the same way previous and identical lines were filled out. If not, leave blank.

• 8

  Indicate whether the injury was related to work, auto or other.

• 9

  Indicate whether a signature of the patient is on file on the signature line. Print "Signature on File" or "SOF" if you have a signature and provide the date the signature was obtained in MM/DD/YYYY format. If not, print "No Signature on File."

• 10

  Use items 14 through 33 to answer specific questions about the patient's illness or injury, health history and medical charges incurred.