How to Complete a CMS 1500 Form

The Form CMS-1500 form is used by healthcare providers to file Medicare claims. It is completed and submitted to Medicare carriers, Part A/B Medicare Administrative Contractors, and Durable Medical Equipment Medicare Administrative Contractors. The Form CMS-1500 is a paper form, standardized for electronic reading by Optical Character Recognition equipment.

Things You'll Need

• Form CMS-1500

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Instructions

• 1

  Select the claim type in Box 1 and enter the patient's identification number from his Benefits ID Card in Box 1a. In Box 2, enter his last name, first name, then middle initial. Do not use commas on Form CMS-1500 claims. Complete the patient's birth date in eight-digit format (MMDDCCYY) and select the appropriate gender checkbox. In Box 5, enter the patient's mailing address and telephone number. In Box 8, select the correct box for patient's marital status and employment.

• 2

  If the patient is also covered by other insurance, list the name of the insured in Box 4. If the patient is the insured person, enter "SAME." If this claim will be the primary claim for the patient, leave Boxes 4, 6 and 7 blank. If Box 4 is completed, also complete Boxes 6, 7 and 11. Box 9 applies to only a small percentage of claims and will not be used unless Medigap coverage is present. In Box 10, select if the claim is due to an accident or injury.

• 3

  Boxes 12 and 13 are signature fields for the patient or his representative. It is appropriate for this field to be marked "on file" if the release is also on file. They must also be dated with six or eight-digit dates in MMDDCCYY format. Enter the date of the onset of illness or the date of the accident in Box 14. Box 15 is not currently used on most claims. If the patient cannot work due to her illness or accident, complete Box 16. In Box 17, enter the name of the referring or ordering healthcare provider. In Box 17b., enter his National Provider Identifier number, or NPI. Box 17a is no longer used. Complete Box 18 if the claim is related to a hospitalization. Box 19 is to be completed when the claim is for routine foot care. Box 20 relates to outside lab work. If outside lab work has been performed, enter the dollar amount. Complete Box 21 by entering all letters and numbers of the ICD-9-CM code for the primary diagnosis. Decimal points are not to be used. Enter secondary diagnosis in Lines 2, 3 and 4. Box 22 is not used and should be left blank. Write the 11-digit treatment authorization number in Box 23 if prior permission was required for the procedure.

• 4

  In Box 24, the shaded area and the white area may be necessary fields. If billing for disposable medical supplies, enter the Universal Product Number in the shaded area of 24a. If billing for physician-administered drugs, write the NDC information in the shaded area in 24a and 24d. In the unshaded portions of Boxes 24a.- b. and d. - g., fill in the date, location code, procedure code, diagnosis code, fee for service, and amount rendered in the appropriate fields. Box 24c. is no longer used. If applicable, mark Early Periodic Screening or Family Planning in Box 24h. Enter service provider's NPI in Box 24j.

• 5

  Enter the provider's Tax ID number in Box 25. Write patient's medical record number in Box 26 in order to assist in locating the files if the Form CMS-1500 is returned. Check the block to indicate if the healthcare service provider accepts assignment of Medicare benefits in Box 27. Complete Boxes 28-30 with the full dollar amount for all services, amount paid, and balance due. Box 31 should be signed and dated by the provider or a representative. Write the provider's name, address, city, state, zip code, phone number and NPI in Box 32. In Box 33, fill in the billing provider's address, phone number and NPI, if different from the service provider's.