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CMS - 1500 BLOCKS
BLOCKS
| Question | Answer |
|---|---|
| BLOCK 1A | MEDICARE HEALTH INSURANCE CLAIM NUMBER |
| BLOCK 2 | PT FIRTS NAME, MIDDLE INITIAL, AND LAST |
| BLOCK 3 | THE PT'S 8 DIGIT BIRTHDATE |
| BLOCK 4 | PRIMARY INSUREDS NAME |
| BLOCK 5 | PT'S MAILING ADDRESS |
| BLOCK 6 | PT'S RELATIONSHIP TO INSURED |
| BLOCK1 | WHERE YOU PUT THE TYPE OF INSURANCE IS APPLICABLE |
| BLOCK 7 | INSUREDS ADDRESS, IF THE ADDRESS IS THE SAME AS PT PUT SAME IN BOX |
| BLOCK 8 | LEAVE BLANK |
| BLOCK 9 A-D | Other (Secondary) Insured's Information - 9) Name 9a) Policy/Group Number 9b) blank 9c) blank 9d) plan name/program name: Employer/School Name, Insurance Plan/Program Name |
| BLOCK 10 A-C | Patient's Condition Relation |
| BLOCK 11 A-D | Insured's Information - Policy/Group Number, Employer/School Name, Insurance Plan/Program Name 11) Policy# 11A) Insured's DOB & Sex 11B) Other claim ID 11C) Insurance Plan Name/Program Name 11D) Is there another health benefit plan? |
| BLOCK 12 | Signature and Date to authorize Release of Information |
| BLOCK 13 | Insured's or Authorized Person's Signature authorizing Payment of Benefits. |
| BLOCK 14 | Date of Current - Illness (First Symptom) OR Injury OR Pregnancy (LMP) |
| BLOCK 15 | LEAVE BLANK |
| BLOCK 16 | Dates Patient Unable to Work in Current Occupation |
| BLOCK 17 A-B | 17) Name of Referring Provider or Other Source 17a) leave blank 17b) ID Number of Referring Physician, NPI - Enter Referring Provider's NPI number. |
| BLOCK 18 | Hospitalization Dates Related to Current Services |
| BLOCK 19 | RESERVED FOR LOCAL USE (additional claim info) |
| BLOCK 20 | OUTSIDE LAB? (check yes or no) |
| BLOCK 21 | Diagnosis CODES (up to 12) |
| BLOCK 22 | LEAVE BLANK (resubmission code) |
| BLOCK 23 | Prior Authorization Number |
| BLOCK 24 A | Date(s) of Service (must be 6 digit date) |
| BLOCK 24 B | PLACE OF SERVICE |
| BLOCK 24 C | Emergency Indicator (leave blank) |
| BLOCK 24 D | Procedures, Services or Supplies (up to 6) and Modifiers (up to 4 each procedure; or a total of 24) |
| BLOCK 24 E | Diagnosis Pointer |
| BLOCK 24 F | CHARGES |
| BLOCK 24 G | # of Days or Units |
| BLOCK 24 H | LEAVE BLANK (says EPSDT Family Plan) |
| BLOCK 24 I | ID Qualifier (put 1C in shaded area) |
| BLOCK 24 J | Rendering Provider ID #/ NPI |
| BLOCK 25 | Federal Tax ID Number |
| BLOCK 26 | Patient's Account Number |
| BLOCK 27 | Accept Assignment? (check off Yes or No) |
| BLOCK 28 | Total Charge |
| BLOCK 29 | Amount Paid - |
| BLOCK 30 | LEAVE BLANK |
| BLOCK 31 | Signature of Physician or Supplier Including Degrees or Credentials and the date. |
| BLOCK 32 | Service Facility Location Information |
| BLOCK 32 A | Service Facility Location Information - Enter the NPI of the facility where the services were rendered. |
| BLOCK 33 | BILLING PROVIDER INFO & PHONE |
| BLOCK 33 A | Billing Provider Info & Phone # (Pay-To, NPI) - Enter the billing provider’s NPI. (leave 33b shaded portion blank) |
Created by:
tarajean1974