Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
2026 CBCS EXAM PREP
2026 CMS 1500 CLAIM FORM BLOCKS
| Term | Definition |
|---|---|
| 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 (X) | LEAVE BLANK RESERVED FOR NUCC USE (Reserved for future updates) |
| 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 (X) | LEAVE BLANK Other Insured’s Policy or Group Number |
| 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 identification card. Ex: 1234 Park Ave. NY 20072 |
| Block 9D | 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 10D (X) | LEAVE BLANK RESERVED FOR NUCC USE |
| 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 11A | Insured’s Date of Birth. Enter Sex as well if different from block 3 |
| Block 11B | 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 11D | Is there another health benefit plan? (If yes complete Block 9, 9a and 9d) |
| 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 (X) | 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 (Block 17) | Referring Provider |
| DK (Block 17) | Ordering Provider |
| DQ (Block 17) | Supervising Provider |
| Block 17A (X) | LEAVE BLANK (Referring provider identification number) |
| Block 17B | 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 (X) | LEAVE BLANK (Resubmission Code) |
| Block 23 | QIO prior Authorization Number If prior authorization is received, indicates the authorization number assigned to the services and dates submitted on this claim. |
| Block 24A | Date(s) of Service MM/DD/CCYY format of the date(s) that the service(s) billed on this claim was performed |
| Block 24B | Place of Service (POS) Location where services billed on this claim were performed. Valid values: National POS codes maintained by CMS. |
| Block 24C (X) | LEAVE BLANK (EMG/Emergency Indicator) |
| Block 24D | Procedures, Services, or Supplies CPT or HCPCS (5-position) code describing the procedures performed, medical services rendered or the supplies furnished. |
| Block 24E | 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 24F | 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 24G | 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 24H (X) | LEAVE BLANK (EPSDT/Family plan) |
| Block 24I (X) | LEAVE BLANK (ID qualifier 1C in the shaded portion) |
| Block 24J | 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 (SSN & EIN) |
| Block 26 | Enter the patient's account number as assigned by the provider or supplier |
| Block 27 | Accept Assignment (Yes or No) 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 (X) | LEAVE BLANK RESERVED FOR NUCC USE (Balance Due) |
| Block 31 | Enter the signature of the provider or signature of an authorized representative including degrees or credentials |
| Block 32 | Enter the name, address, and ZIP code of the facility where services were rendered |
| Block 32A | Enter the NPI of the facility. |
| Block 32B (X) | LEAVE BLANK (ID Qualifier and PIN) |
| Block 33 | The provider’s or supplier’s name, office street address and/or P.O. box, zip code, telephone number |
| Block 33A | NPI number of the billing provider or group |
| Block 33B (X) | LEAVE BLANK (ID Qualifier and PIN) |
| CMS 1500 CLAIM FORM BLOCKS | aka HCFA 1500; most widely used health insurance claim form in the medical billing industry; developed by the National Uniform Claim Committee (NUCC) |
Created by:
C to the C
Popular Medical sets