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. |
| 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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