You should follow the steps below when filling out the cms 1500 Claim Form

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You should follow the steps below when filling out the CMS 1500 Claim Form:

  1. Fill out sections 1 – 11 with information about the patient and the subscriber on the account. Required boxes in this section are: 1A, 2, 3, 4, 5, 6, 7 and 11D.

  • Note: On 11D (Is there another health benefit plan?), check the appropriate box. If YES is checked, then fields 9A – 9D must be completed.

  1. Box 12 requires the patient’s or authorized person’s signature.

  1. If you sign or mark Box 13 in any manner, this may prompt payment to be sent to the provider. Only sign Box 13 if you want monies to be sent to the provider. The patient should not sign within Box 13 if the patient is being treated by an out-of-network provider and reimbursement should be sent to the patient.

  • Note: Do not make any marks in this box if you would like to receive payment.

  1. Boxes 14 – 33 are not required if you have an itemized bill from the provider that shows the following:

  • Federal Tax Identification Number (FTIN)

  • Provider name

  • National Provider Identification number (NPI)

  • Billing address of the rendering provider

And shows the following for each date of service:

  1. If you do not have an itemized bill, you will need to complete the following boxes:

    • 17 (Name of referring physician or other source): If patient was referred to the current physician by another physician, a hospital or clinic, the referring provider should be entered here.

    • 17B (NPI number of physician): Enter the NPI number of the referring/ordering physician entered in Box 17.

    • 21 (Diagnosis or nature of illness or injury): The diagnosis explains why the patient went to see the provider. Both an ICD-9 code and a description should be indicated.

    • 24A (Date(s) of service): Enter the date service was rendered by the provider. The complete From and To date should be entered as MM/DD/YY.

    • 24B (Place of service): Enter the location code for where the services were performed.

    • 24D (Procedure Code/Modifier Code): Enter the 5-digit procedure code.

    • 24F (Charges): Enter the charge per line of service.

    • 24G (Days or Units): Enter the number of times a service was performed.

    • 24J (Rendering Provider ID number): Enter the NPI number of the provider rendering services.

    • 25 (Federal Tax ID Number): Enter the provider's Federal Tax Identification Number (FTIN) or the provider's Social Security Number.

    • 28 (Total Charge): Enter the total charge of the claim.

    • 32 (Name and address of facility where services were rendered): If this information is the same as Box 33, it may be left blank.

    • 33 (Physician's/Supplier's billing name, address, ZIP code and telephone number): Enter name, address and telephone number of the physician or supplier of service.

Tips on Completing the CMS-1500 Claim Form

  • Be sure that all required fields are completed.

  • Handwritten claims should be printed neatly and accurately, preferably using a black ballpoint pen.

  • Do not sign or write in red ink.

  • Do not use a highlighter on the form.

  • Use upper case (CAPITAL) letters.

  • Use only alphabetical letters or numbers. Symbols (i.e., $, #, cc, etc.) should not be used. Omit commas, periods or decimal points.

  • Be sure that all diagnoses have related procedures and all procedures have related diagnoses.

  • Be sure to keep a copy of the claim form and receipts for personal records.

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