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CBCS CMS 1500 form

Block 1 Type of Health Insurance Coverage applicable to Claim
Block 1A Insured’s ID Number (HICN)
Block 2 Patient’s Name (Last Name, First Name, Middle Initial)
Block 3 Patient’s eight digit birth date and sex. MM/DD/CCYY
Block 4 If there is an insurance primary to Medicare: Insured’s Name (Last Name, First Name and Middle Initial). If patient and insured are the same write same. If Medicare is primary leave blank
Block 5 Patient’s mailing address and telephone number. mailing address on the first line and city and state on the second line, zip code and phone number on the third line.
Block 6 Patient Relationship to Insured
Block 7 Enter the insured's address and phone number. If the insured is the same as the patient, write same. Complete this block after block 4, 6, and 11 have been completed.
Block 8 leave blank
Block 9 Last name, first name, and middle initial (if any) of the Medigap enrollee if it is a different person from the one listed in Block 2. Otherwise, write SAME. If no Medigap benefits are assigned, leave blank.
Block 9A Enter the policy and group number of the Medigap insured preceded by Medigap, MG, MGAP.
Block 9B Leave blank
Block 9C Leave blank if block 9d is filled out. otherwise, enter the claims processing address of the Medigap insurer. Use abbreviated street address, two letter postal code, and Zip code from the Medigap insured's idetification card. Ex: 1234 Park Ave. NY 20072
Block 9 D Write in the Coordination of Benefits Agreement Medigap-based identifier
Block 10A-C Check "Yes" or "No" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services listed in block 24. A "yes" answer indicates there might be other insurance primary to Medicare
Block 11 Indicates that a good faith effort has been made to determine whether Medicare is the primary insurance. Information about insurance primary to medicare should be listed in blocks 11a-11c.
Block 11 A Insured’s Date of Birth.Enter Sex as well if different from block 3
Block 11 B Enter employer's name and any change in insurance status
Block 11C Enter the nine digit payer ID number of the primary insurer. If there is no payer ID, then write in the primary payer's program or plan name, If the Explanation of benefits (EOB) does not include the claim's processing address, then write it in.
Block 11 D leave blank
Block 12 Patient’s or Authorized Person’s Signature
Block 13 This signature authorizes payment of benefits to the physician or supplier.
Block 14 either a six or eight digit date of current illness, injury, or pregnancy: MMDDYY or MMDDCCYY. only one style of date can be used consistently throughout the claim
Block 15 leave blank. only used if provider is seeing patient in a facility
Block 16 Dates Patient Unable to Work in Current Occupation
Block 17 Name of Referring Provider or Other Source
DN Referring Provider
DK Ordering Provider
DQ Supervising Provider
Block 17 A leave blank
Block 17 B NPI# (National Provider Identifier)
Block 18 Date entered in either a six or eight digit format when a medical service rendered is a result of, or subsequent to, a related hospitalization.
Block 19 Dates entered in either a six or eight digit format for when the patient was last seen and the NPI of the attending physician when a physician providing routine foot care submits claim.
Block 20 Mark "yes" to the question asked if lab tests were done by an entity other than the one doing the billing. if multiple tests are involved, each should be filled under a separate claim.
Block 21 Diagnosis or Nature of Illness or Injury
Block 22 leave blank
Block 23 The QIO prior Authorization Number goes here If prior authorization is received, indicates the authorization number assigned to the services and dates submitted on this claim.
Block 24 A Date(s) of Service MM/DD/CCYY format of the date(s) that the service(s) billed on this claim was performed
Block 24 B Place of Service (POS) Location where services billed on this claim were performed. Valid values: National POS codes maintained by CMS.
Block 24 C Medicare providers do not have to fill out this field,
Block 24 D Procedures, Services, or Supplies CPT or HCPCS (5-position) code describing the procedures performed, medical services rendered or the supplies furnished.
Block 24 E Diagnosis Pointer Indicates that the service provided was treatment for one or more of the specified “diagnosis codes” identified in Box 21. Required even if there is only one diagnosis.
Block 24 F Enter the provider's billed charges for each service The per line item charge(s) for the procedure(s) performed including any applicable patient copay amounts.
Block 24 G Enter the number of days or units Number of identical medical, surgical or anesthesia services performed, or number of pints of blood supplied as related to the corresponding procedure code.
Block 24 H Leave blank
Block 24 I Enter the ID qualifier 1C in the shaded portion
Block 24 J Enter the rendering provider's NPI in the un-shaded portion
Block 25 Enter the provider's or supplier's federal ID number or social security number and check the appropriate box
Block 26 Enter the patients account number as assigned by the provider or supplier
Block 27 Check the appropriate box to indicate whether the provider or supplier accepts assignment of Medicare benefits. Be aware of which providers can only be paid on an assignment basis
Block 28 Enter the total charge of all services
Block 29 Enter the total amount the patient paid for covered services only
Block 30 Leave blank
Block 31 Enter the signature of the provider or signature of an authorized representative
Block 32 Enter the name, address, and ZIP code of the facility where services were rendered
Block 32 A Enter the NPI of the facility.
Block 33 The provider’s or supplier’s name, office street address and/or P.O. box, zip code, telephone number
Block 33 A NPI number of the billing provider or group
Created by: drea08