AFAMEP

FORM
CMS 1500

FAMEP
ASSOCIATION OF Medical BILLERS
PUERTO RICO, INC.

Health Services Billing

FORM
CMS 1500

Important Considerations When

Completing Form CMS-1500

► The CMS-1500 claim form was

previously known as HCFA-1500. Only
the formulary prefix has changed from
HCFA to CMS. Versions with the HCFA
prefix can be used until further notice.
► These instructions pertain to claims
submitted on paper only and help us
understand the entry of information for
electronic transactions.

FORM
CMS 1500
► The CMS-1500 (Health Insurance
 Claim Form) answers the needs of
many health insurers. It is the basic
form prescribed by the Centers for
Medicare and Medicaid Services (CMS)
for submitting claims on behalf of their
Medicare patients. The current version
of the CMS-1500 is (08-05) in red ink.
► The instructions for completing the
CMS-1500 claim form were
implemented by CMS to standardize
the submission of claims to Medicare
Part B contractors. Private insurers
adopted it.
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 FORM
CMS 1500

At the top right, write the name and

address of the medical plan you
are billing.
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CMS 1500
► ITEM 1

► Medicare
► Medicaid
► SHAMPOOS
^ Active members in the Armed Forces
► CHAMPVA
^ Descendants of dead veterans
► Group Health Plan
^ ALL business plan; MCS, Humana, Cosvi, First
Medical, Cigna, Triple S, Cruz Azul, Preferred Health,
etc.
► BLK LUNG
► Coal mine workers
► Other
► Reform, HMO, Advantage
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CMS 1500
► Item 1

► All medical plans require

completion of this Item.
► Enter the patient ID number as
it appears on the medical plan
card, for all claims (primary or
secondary).
► Item 2
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CMS 1500
► Last name, First name, Initial
All medical plans require
completion of this Item.
Enter the last name, first name
and initial , if any, of the patient
as it appears on the medical plan
card.
► Item 3

Enter the 8 digits of the patient's

 FORM
date of birth (MM DD CCYY) and
check the box appropriate to the
patient's sex.
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CMS 1500
► Item 4

(Last name, First name,

Initial)

Enter the name of the primary

insured for the primary
insurance, whether the patient
or spouse or any other source.
► Item 5
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CMS 1500

Enter the patient's postal address and

telephone number. Enter the street on the
first line, the city and state on the second,
and the zip code and phone number on the
third.
► Note: For home visits performed at a location other than
the patient's mailing address, enter the patient's mailing
address in Item 5 and the complete address, including the
zip code, of the location where the home visit was actually
provided in Item 5. service.

► Item 6
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Check the appropriate square

indicating the relationship of the
patient to the insured.
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CMS 1500
► Item 7

Enter the address and

telephone number of the
primary insured.
► Item 8
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Check the appropriate box(es)

for the patient's marital status or
whether he or she is employed
or a student.
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CMS 1500
► Item 9
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)

to. OTHER INSURED'S POLICY OR GROUP NUMBER

b. OTHER INSURED'S DATE OF BIRTH sex

MM DD YY _____ _________________

I I |M| | F| Yo
c. EMPLOYER'S NAME OR SCHOOL NAME

They should be completed only when the

patient has a second medical plan and
the providers have a participating
doctor
Enter the last name, first name and initial
of the insured in the second medical
plan, if it is different from that
indicated in Item 2.
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CMS 1500
Item 10a to 10c

► Check "YES" or "NO" to indicate if employment,

automobile, or other type of accident applies to
one or more of the services described in Item 24.
► Enter the state's two-letter ZIP code (Example: PR)
for automobile accidents when Item 10b is
checked “YES.”
► Any item marked "YES" indicates that there may
be other insurance primary to the patient's medical
plan (AACA, CFSE).
► Identify the primary insurance information in Item
11.
► Item 10d
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CMS 1500

RESERVED FOR LOCAL USE

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CMS 1500

► INSUREDS POLICY GROUP OR FECA

NUMBER Medicare requires this Item to be
completed.

► Item 11
This Item must be completed. By completing it, the
provider acknowledges that they have made a good
faith effort to determine whether Medicare is the
primary or secondary payer.

If there is no insurance primary to Medicare,

indicate “None” and continue to Item 12.

If there is insurance primary to Medicare, indicate

the number
policy or group group of the insured and
 continue to Items 11a to 11c. When you complete
Items 11a through 11c, also complete Items 4, 6,
and 7.

► Enter the word "NONE" if there has been a change

in the insured's insurance status; (for example,
retired) and continue to Item 11b.
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CMS 1500

► Circumstances under which Medicare

payment may be secondary to other
insurance include patients covered by:
► Group Health Plan Coverage:
^ People 65 years of age or older who work
(“Working Aged”);
^ Disability (group health plan of one hundred or
more employees);
^ End Stage Renal Disease (ESRD);
^ Public Liability Insurance and bodily injury
and property damage insurance of the
insured
^ Work-Related Illness/Injury:
^ Compensation for work accidents;
^ Black lung (“Black Lung”);
^ Veterans Administration
► Item 11a
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CMS 1500

Enter the 8 numbers of the

insured's date of birth and sex, if
they are different from those in
item 3.
► Item 11b
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CMS 1500

Enter the name of the employer,

if applicable. If there is a change
in the insured's insurance status,
(for example, retired) enter the
8 digits of the retirement date
after the word "Retired."
► Item 11c

Enter the full name of the

insurance plan or company. If
the primary payer's Explanation
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CMS 1500

of Benefits (EOB) does not

contain the address of where
claims are processed , record
the claims processing address
directly on the EOB.
► Item 11d
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CMS 1500

Leave blank. Not required by

Medicare.
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CMS 1500
► Item 12

► Enter the signature of either the patient or an

authorized person and the date.

► The patient or their authorized representative must

sign and enter the 8-digit date (MM DD YYYY ) or
an alphanumeric date (for example, January 1,
2002).

► Enter: "Signature on file" (SOF)

► Patient authorization must be obtained

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CMS 1500
before billing Medicare for all services for
which the beneficiary is physically present.
The only exempt services are diagnostic or
test interpretation services, in which the
beneficiary neither visits the provider or
supplier nor is visited by a representative
of the provider in connection with the
services.

► The patient's signature authorizes the

release of medical information to process
the claim. It also authorizes payment of
benefits to the service provider or supplier
when he or she accepts assignment of the
claim.

CMS 1500
► Physically or mentally unable to sign: If the
patient is physically or mentally unable to
sign, a representative may sign on the
patient's behalf. In this case, the
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CMS 1500
statement must indicate the name of the
patient, followed by "by" and the
signature of the representative, his or
her address, his or her relationship to the
patient, and the reason why the patient
cannot sign. If the patient does not have a
representative present, and verbal consent
can be obtained, the medical staff who
obtained verbal consent may sign.

► One mark per signature (X):

When an illiterate or physically
incapacitated beneficiary signs with a
mark, a witness must enter his or her
name and address near the mark.

CMS 1500
► Signature on File (SOF):
Providers who submit claims to Medicare over an
extended period of time, or electronically, have the
option of entering into a single-signature
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CMS 1500
authorization agreement with the patient. This will
save the inconvenience of having to obtain the
patient's signature for each claim submitted to
Medicare.

► The statement or copy of the statement should not

be sent to the Medicare contractor.
The signed agreement(s) must be maintained with
the patient's record in the provider's files.

► The authorization can be for life. It does not have

to be for a specific period of time and the patient
can cancel at any time. This agreement is effective
on the date of signature and is effective indefinitely
unless the arrangement is revoked by the patient or
his or her representative.
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CMS 1500
► The written agreement should look similar to the
following example.
► EXAMPLE
(Authorization to Keep Signature on File on Provider
Letterhead)

Name of Patient: Health

Insurance Claim Number (HICN):

I request that payment of authorized Medicare

benefits be made either to me or on my behalf to
____________________ for services furnished to
me by the provider. I authorize any holder of
medical information about me to release to the
Centers for Medicare & Medicaid Services and its
agents any information needed to determine these
benefits or the benefits payable for related service

PATIENT'S Signature date

 FORM
► During a review, Medicare may
request that you provide them
with a “Signature on File”
document or the patient's
signature.
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CMS 1500

► Item 13
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of
medical benefits to the undersigned physician or supplier for services described
below.

SIGNED

The signature on this Item

authorizes
the payment of Medigap
mandated benefits to the
participating physician or
supplier if the information
required by Medigap is
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CMS 1500

included in Item 9 and its

subdivisions.

► Item 14

► Enter the 8 digits of the date (MM

DD YYYY) of the current illness,
injury or pregnancy.
► Chiropractic Services : Enter the 8
digits of the date (MM DD YYYY) of
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CMS 1500

the start of treatment

► Item 15

Leave blank. Not required by

Medicare.
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CMS 1500
► Item 16

Enter the 8 digits of the date (MM

DD YYYY) when the patient is
employed and unable to work in
their current occupation. An entry in
this field may indicate employment-
related coverage (e.g., MSP
Workers' Compensation).
CMS 1500
► Item 17, 17a and 17b
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CMS 1500

Enter the name of the doctor who refers or

orders the service

a-Other identification number

b-NPI (National Provider Identification

Number)
If the service or item was ordered or
referred by a doctor.

CMS 1500
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CMS 1500
► 17a Another identification
number is chosen from the
following list

► 0B State License Number

► 1B Blue Shield Provider Number
► 1C Medicare Provider Number
► 1D Medicaid Provider Number
► 1G Provider UPIN Number
► 1H CHAMPUS Identification Number
► EI Employer's Identification Number
► G2 Supplier Commercial Number
► LU L o cation Number
► N5 Provider Plan Network Identification Number
► SY Social Security Number (The social security
number may not be used for Medicare.)
► X5 State Industrial Accident Provider Number
► ZZ Provider Taxonomy
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CMS 1500
► 0B State License Number
► 1B Cruz Azul Supplier Number
► 1C Medicare Provider Number
► 1D Medicaid Provider Number
► 1G Provider Number UPIN
► 1H CHAMPUS Number
► E1 Employee Identification Number
► G2 Commercial Supplier Number
► LU Facility Location Number
► N5 Network Plan Provider Identification Number
► SY Social Security Number (Not used for Medicare)
► X5 Supplier Number Industrial Accidents
► ZZ Number Taxonomic Code

CMS 1500
► Referring Physician: A physician who
requests an item or service for the
beneficiary (payable under the
 FORM
Medicare program). Ordering
physician: is a physician who orders
non-medical services for the patient
such as diagnostic laboratory
services, clinical laboratory tests,
pharmaceutical services, or durable
medical equipment .
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CMS 1500

► Item 18

Enter the 8-digit (MM DD YYYY) date

when a medical service is provided
as a result of, or subsequent to, a
related hospitalization.
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CMS 1500

► Item 19

It can be used for the purpose of

identification or other
instruction.
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CMS 1500
CMS 1500
► Item 20

Check "YES" when an entity other than the one billing

for the service performed the diagnostic exam. If you
check "yes", enter the purchase price in $CHARGES and
also complete Item 32.

► When billing for multiple diagnostic tests purchased,

each test must be submitted separately on a completed
CMS-1500 claim form.

► Check "NO" when the claim does not include purchased

evidence.

► Leave blank for services that are not affected by the

purchased tests indicator modifier. Any non-applicable
entry in this Item may result in denial of payment for the
reported service.
 FORM
► Item 21

All physicians are required to complete this Item.

► Enter the patient's diagnosis/condition. All medical

and non-medical specialties must use an ICD-9-CM
code number and assign a code to the highest
degree of specificity. Enter up to 4 codes in priority
order (primary, secondary condition ).

► An independent laboratory must enter a diagnosis

only for limited coverage procedures. The entire
diagnostic description must be submitted in an
annex.
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CMS 1500
CMS 1500
► Truncated or incomplete diagnostic codes
are not acceptable. Many Medicare
policies are diagnosis-specific. The ICD9-
CM code lists cover a wide range that
includes truncated codes. The provider's
responsibility is to avoid trick codes by
selecting a code at the highest level of
specificity, selected from the ICD-9-CM
coding book appropriate to the year in
which the claim is submitted. Many
diagnosis codes are removed, added, or
more specific each year. It is very
important that you have the updated ICD-
9-CM book in your office.
 FORM
CMS 1500

► Item 22

The original transaction number

is written when the service is
rebilled.
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CMS 1500

► Item 23

Certain procedures must be

pre-authorized and the
authorization number is written
in this box.
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CMS 1500

► Item
24A
► Enter an 8-digit date
(MMDDYYYY) for each
procedure, service or
supply
► Note: When “from” and “to
or to” are indicated for a
series of identical services :

► Dates on a line should not

override months or years.
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CMS 1500
► Time Limit to Submit Claims:
► For services rendered between:
Claims must be submitted before:
► October 1, 2003 and September 30,
2004, December 31, 2005
► October 1, 2004 and September 30,
2005
December 31, 2006
► October 1, 2005 and September 30,
2006
December 31, 2007
 FORM
CMS 1500
► Item 24 B

►B Place of Service
Medicare requires
completion of this Item.
► Enter the appropriate 2-
position code for the place of
service (POS) to identify the
location where the
car the place
it's where the article H
or where
provides the service.
► When reporting another
place of service other than
office ill) or hoqar (12),
, requires
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CMS 1500
completing Item 32.
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CMS 1500

► Item 24
C IT IS IDENTIFIED IF
THE SERVICE WAS
AN EMERGENCY

AND - AND IS N -NO

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CMS 1500

► Enter the appropriate CPT or

HCPCS code. Enter the specific
procedure code without narrative
description .
► MODIFIER: Completion of this
portion of the item is conditional.
► Note: When indicating a “not
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CMS 1500
otherwise classified” (NOC)
procedure code, include a
narrative description in Item 19.
If you cannot provide a
consistent description within the
limits of Item 19, you must
submit an annex with the claim.
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CMS 1500
CODE DIAGNOSIS

► Item 24
E from
Indicate the diagnosis code reference number
Item 21 to relate the date of
service and procedures performed to
the primary.

► Enter only one reference number per

line.
► Enter 1, 2, 3, or 4. Just a number of
reference is necessary per coding
line.

► Note: Submitting improper ICD-9 CM

codes may result in a return of the claim or a denial
for medical necessity. Remember to relate the ICD-9
CM code to the coding line.
 FORM
CMS 1500
► Item 24 F

► Enter the charge for each

listed service. The
submitted charge
reported in Item 24F
must be the total charges
for the days or units
reported in Item 24G.
► Non-participating
providers must not exceed the
service charge limit.
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CMS 1500
► Item 24 G
► Indicate the number of days or units.
This field is most commonly used for
multiple visits, units of supplies,
minutes of anesthesia, or volume of
oxygen. If only one service is
rendered, number 1 must be entered.
► Note: The period designated by
consecutive dates of care billed in Item
24A and the number of services entered
in Item 24G must be equal
► For anesthesia:
Please indicate the total elapsed time
as minutes in item 24G
► Note: Convert hours to minutes and
enter the total minutes required by the
procedure.
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CMS 1500
► Item 24H

► It is not filled out unless

the plan requests it
► Item 24H

► Note can be used for:

► AV Available – Not Used (Patient refused

referral.)
► S2 Under Treatment (Patient is currently
under treatment for referred diagnosis or
corrective health problem.)
► ST New Service Requested (Referral to
another provider for diagnosis or corrective
treatment/ scheduled for another appointment with
screening provider for diagnosis or corrective
treatment for at least one health problem identified
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CMS 1500
during an initial or periodic screening service, not
including dental referrals.)
► NU Not Used (Used when no EPSDT patient referral
was given.)
► If the service is Family Planning, enter Y (“YES”) or N
(“NO”) in the bottom, unshaded area of the field.
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CMS 1500
Item 24I
ID Identifier of the Provider
that provides the service
and NPI
0B State License Number
1B Blue Shield Provider Number
1C Medicare Provider Number
1D Medicaid Provider Number
1G Provider UPIN Number
1H CHAMPUS Identification Number
EI Employer's Identification Number
G2 Supplier Commercial Number
LU Location Number
N5 Provider Plan Network Identification Number
SY Social Security Number (The social security
number may not be used for Medicare.)
X5 State Industrial Accident Provider Number
ZZ Provider Taxonomy
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CMS 1500
► Item 24J

► In the first the ID

number and in
the second the
NPI number
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CMS 1500
► Item 25

Enter your federal tax identification number

(Employer Identification Number), or Enter
your Social Security Number (SSN).

► Note: Mandated transfer to Medigap

requires the Federal Tax Identification
Number of the participating provider or
supplier. Refer to Item 9 and its
subdivisions.

► Item 26
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CMS 1500

This is an optional field for the

provider/supplier to facilitate patient
identification. Any account number included
will be indicated on the supplier's shipment.
► Enter the patient account number assigned
by the provider/supplier system.
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CMS 1500
► Item 27

Check the appropriate box to indicate

whether the provider/supplier accepts
assignment of Medicare benefits.
Participating providers have signed
agreements with their contractors to
always accept assignment of Medi care
benefits for all covered charges for all
patients when Medicare-covered services
are rendered . Non-participating providers
accept or decline assignment of Medicare
benefits on a case-by-case basis.

► Item 28
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CMS 1500

Please indicate total charges for

all services. This total must equal
the sum of all charges in Item
24F.

CcccCCCCCCcc
$$$$$$$$$$$$$

► Item 29
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CMS 1500

Please indicate the total amount paid by

the patient for this claim. This applies
to the deductible amount and any
amount additional to 20%.
► Note: Do not list any amounts
previously paid by Medicare in this
Item.
► Item 30
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CMS 1500
Total balance after subtracting co-
payment
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CMS 1500

Item 31

Indicate the signature of the

supplier/supplier, its representative or the
computer-generated signature and the 8-
digit date (MM DD YYYY) or alphanumeric
date

(Ex. January 1, 2002) when the form was signed.

Either a signature seal or the doctor's printed
signature is acceptable.
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CMS 1500
► Item 32
32. SERVICE FACILITY LOCATION INFORMATION

to. b.

► This Item is conditioned by the place of

service. When required, indicate the name
and complete address with the zip code
included.
► The contractor's jurisdiction depends on
where the services were provided.
Claims with addresses out of jurisdiction
will be returned as non-processable.
► to ID number
► b NPI number
► Indicate the name and full address of the entity if
 FORM
CMS 1500
the services were provided at a location other than
the patient's home or doctor's office.
► Beginning April 1, 2004, list the name and address
with the zip code of the place of service for all
services that are not provided in the home (place
of service 12). Only one name, address and postal
area must be indicated in Item 32. If additional
entries are required, separate claim forms must be
submitted.

► Note :
For home visits in a town other than the patient's
mailing address: Indicate in Item 5 the patient's
mailing address. Indicate in Item 32 the complete
address and postal area where the service was
provided.

► Item 33
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CMS 1500

► Indicate the name with which you

invoice, address, zip code and
telephone number of the
supplier/supplier.
► Individual Providers:
Indicate the supplier number (PIN)
assigned by the contractor in a and
the NPI number in b.