Article-What-information-is-required-on-CMS-1500-form

When a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims then non-institutional providers or suppliers are using CMS-1500 form which is the standard claim form to bill Medicare carriers and durable medical equipment regional carriers (DMERCs).

Following information fields are required on CMS 1500 form:

 

Field

Description 

Additional Explanation

  Carrier Block

Enter the name and address of the insurance Carrier being billed.

1a Insured’s ID number List the Insured’s identification number here.
2 Patient’s Name Enter the patient’s name as it appears on the Insurance identification card.
3 Patient’s birth date and gender Enter the patient’s birth date and sex.
4 Insured’s name Enter the insured’s full last name, first name and

middle initial enter it after the last name, but before the first name. If the insured has a last name suffix (e.g., Jr, Sr)

5 Patient’s Address Enter the patient’s address, if the patient is homeless

or address is unknown enter NKA, No Known Address, Unknown or Homeless.

12 Patient’s or Authorized Person’s Signature Enter the patient’s or authorized person’s signature.
13 Insured’s or Authorized Person’s Signature Enter the patient’s or authorized person’s signature.
17 Name of referring physician or other sources Provide the name of the referring physician or other sources if applicable.
17b Referring/Ordering NPI Enter the NPI of the referring or ordering physician listed in item 17 as soon as it is available.
21 Diagnosis or nature of illness or injury Enter a valid ICD-9 diagnosis code.
22 Resubmission and/or Original Reference Number Enter frequency code “7” along with the original claim number if submitting a corrected claim.
24 Shaded Section 24 Enter NDC information here. Include the NDC, units, and units of measure. The claim will be denied if NDC is required but missing.

Enter DME descriptions. The claim will be denied if a description is required but missing.
Enter unspecified 99 code descriptions. Enter anesthesia time spans and minutes.

24A Date(s) of Service Enter both the “From” and “To” dates. If only one date is billed enter it under the “From” date.
24B Place of Service Enter the two-digit Place of Service Code for each item or service billed.
24D Procedures, Services, or Supplies Enter the CPT or HCPCS code and modifier (if applicable) for each item or service billed.
24E Diagnosis Pointer Enter the related diagnosis pointer(s) from box 21, A-L.
24F Charges Enter the provider’s billed charges for each service.
24G Units or Days Enter the appropriate number of units or days that correspond to the “From” and “To” dates indicated in Field 24a.
24J Rendering Provider ID Required when billed with a rendering provider. If billing locum tenens provider the locum information must be entered here.
25 Federal Tax ID or SSN Enter the billing provider’s Tax ID or SSN of the provider billed in box 33.
28 Total Charge (Billed Amount) Enter the total bill for all line items combined.
31 Signature of Physician or Supplier Including Degrees or Credentials Enter the provider, supplier, or their representative’s legal signature, along with the date the form was signed.
33 Billing Provider Info and Phone Number Enter the provider or supplier’s billing name, address, ZIP code, and phone number.
33A Billing Provider NPI Enter the provider or supplier’s NPI.

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Published By - Medical Billers and Coders
Published Date - Apr-01-2021 Back

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