How to Fill Out the CMS 1500 Claim Form

Medicare claims not filed through the electronic system must be filed on the Form CMS-1500, a pre-printed form optimized for optical character recognition (OCR) electronic reading. The completed form is submitted to Medicare carriers and contractors for reimbursement of expenses health care providers spend on Medicare patients. While most claims are currently filed through the Accredited Standards Committee (ASC) X12N 837 professional electronic filing format, there are some claims that are still filed by completing the Form CMS-1500.

Things You'll Need

• CMS-1500 form
• Black ink pen

Show More

Instructions

• 1

  Complete sections 1-3, 5 and 8, which are general information about the patient. Write in black ink only or type the answers. Complete sections 4, 6, 7 and 11 if the patient is also covered by other insurance. Respond to the questions in these sections if applicable. Complete Section 9 if Medigap coverage is present. If not, leave this field blank. In Section 10, select the applicable box if the claim is due to an accident or injury. Have the patient sign sections 12 and 13, and date.

• 2

  Section 15 can be left blank. Complete Section 16 if the patient is out of work due to the illness, accident or treatment. Write the name and National Provider Identifier (NPI) number of the health care provider ordering the treatment in Section 17. Section 18 is used when the claim relates to hospitalization. Complete this section if applicable. Complete Section 20 if outside lab work is included in the claim.

• 3

  Enter the ICD-9-CM code for the primary and secondary diagnosis in Section 21. Some knowledge of medical coding is needed for this section. Section 22 should be left blank. If prior permission was required for the procedure, write the 11-digit permission code in Section 23.

• 4

  Complete the white boxes of Section 24 with the applicable information. In the pink shaded section, enter the Universal Product Number or the NDC information for any pharmaceuticals or other disposable medical supplies. Complete Section 25 with the provider's Tax ID or Employer ID number. If the provider accepts assignment of Medicare benefits, fill out Section 27.

• 5

  Write the amount owed for services in Section 28, and the amount already paid in Section 29. Section 30 is for the balance due, although this field is not required. A representative of the provider should complete Sections 31 and 32. Complete Section 33 with contact information if an outside billing agency is used.