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INSUR {McGH}
CMS-1500 insurance claim form
| Term | Definition |
|---|---|
| ITEM NUMBER 1 | Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other |
| ITEM NUMBER 1a | Insured’s ID Number |
| ITEM NUMBER 2 | Patient’s Name |
| ITEM NUMBER 3 | Patient’s Birth Date, Sex |
| ITEM NUMBER 4 | Insured’s Name |
| ITEM NUMBER 5 | Patient’s Address (multiple fields) |
| ITEM NUMBER 6 | Patient Relationship to Insured |
| ITEM NUMBER 7 | Insured’s Address (multiple fields) |
| ITEM NUMBER 8 | Reserved for NUCC Use |
| ITEM NUMBER 9 | Other Insured’s Name |
| ITEM NUMBER 9a | Other Insured’s Policy or Group Number |
| ITEM NUMBER 9b | Reserved for NUCC Use |
| ITEM NUMBER 9c | Reserved for NUCC Use |
| ITEM NUMBER 9d | Insurance Plan Name or Program Name |
| ITEM NUMBER 10a-10c | Is Patient’s Condition Related To: |
| ITEM NUMBER 10d | Claim Codes (Designated by NUCC) |
| ITEM NUMBER 11 | Insured’s Policy, Group, or FECA Number |
| ITEM NUMBER 11a | Insured’s Date of Birth, Sex |
| ITEM NUMBER 11b | Other Claim ID (Designated by NUCC) |
| ITEM NUMBER 11c | Insurance Plan Name or Program Name |
| ITEM NUMBER 11d | Is there another Health Benefit Plan? |
| ITEM NUMBER 12 | Patient’s or Authorized Person’s Signature |
| ITEM NUMBER 13 | Insured’s or Authorized Person’s Signature |
| ITEM NUMBER 14 | Date of Current Illness, Injury, or Pregnancy (LMP) |
| ITEM NUMBER 15 | Other Date |
| ITEM NUMBER 16 | Dates Patient Unable to Work in Current Occupation |
| ITEM NUMBER 17 | Name of Referring Provider or Other Source |
| ITEM NUMBER 17a | Other ID# |
| ITEM NUMBER 17b | NPI # |
| ITEM NUMBER 18 | Hospitalization Dates Related to Current Services |
| ITEM NUMBER 19 | Additional Claim Information (Designated by NUCC) |
| ITEM NUMBER 20 | Outside Lab? $Charges |
| ITEM NUMBER 21 | Diagnosis or Nature of Illness or Injury |
| ITEM NUMBER 22 | Resubmission and/or Original Reference Number |
| ITEM NUMBER 23 | Prior Authorization Number |
| ITEM NUMBER 24a | Date(s) of Service [lines 1–6] |
| ITEM NUMBER 24b | Place of Service [lines 1–6] |
| ITEM NUMBER 24c | EMG [lines 1–6] |
| ITEM NUMBER 24d | Procedures, Services, or Supplies [lines 1–6] |
| ITEM NUMBER 24e | Diagnosis Pointer [lines 1–6] |
| ITEM NUMBER 24f | $Charges [lines 1–6] |
| ITEM NUMBER 24g | Days or Units [lines 1–6] |
| ITEM NUMBER 24h | EPSDT/Family Plan [lines 1–6] |
| ITEM NUMBER 24i | ID Qualifier [lines 1–6] |
| ITEM NUMBER 24j | Rendering Provider ID # [lines 1–6] |
| ITEM NUMBER 25 | Federal Tax ID Number |
| ITEM NUMBER 26 | Patient’s Account No. |
| ITEM NUMBER 27 | Accept Assignment? |
| ITEM NUMBER 28 | Total Charge |
| ITEM NUMBER 29 | Amount Paid |
| ITEM NUMBER 30 | Reserved for NUCC Use |
| ITEM NUMBER 31 | Signature of Physician or Supplier Including Degrees or Credentials |
| ITEM NUMBER 32 | Service Facility Location Information |
| ITEM NUMBER 32a | NPI# |
| ITEM NUMBER 32b | Other ID# |
| ITEM NUMBER 33 | Billing Provider Info & Ph # |
| ITEM NUMBER 33a | NPI# |
| ITEM NUMBER 33b | Other ID# |
Created by:
VA_MedCod3r