CMS 1500 Form also known as HCFA 1500 and has 33 blocks. This form is used by providers to submit a claim to the insurance company for the reimbursement of the health care services rendered to patients.
| CMS 1500 Blocks | Description | Instructions to fill out | Required/Optional Block |
|---|---|---|---|
| CMS 1500 Block 1 | There are seven varieties of health insurance plan to select from. | Select one amongst the seven varities of health insurance plant by ticking(X) suitable Block from the list. | Optional Block (If applicable) |
| CMS 1500 Block 1a | Insured's Insurance Identification Number | Enter the Insured's ID number, which is displayed on the insurance ID card for the insurance to which the claim is being billed. | Required Block |
| CMS 1500 Block 2 | Name of the Patient | Enter the name of the Patient (Last name, fore name and middle initial). | Required Block |
| CMS 1500 Block 3 | Patient's Birth Date and Sex (Male/Female) | Enter the Patient's Birth date in MM/DD/YYYY format and indicate the gender (Male/Female) of the Patient by ticking the Block. | Required Block |
| CMS 1500 Block 4 | Insured's Name | This Block is optional only if Insured and patient are same. If the patient name is different from Insured's name, then we would like to enter insured's name. | Optional Block (If applicable) |
| CMS 1500 Block 5 | Patient's Address together with Telephone Number | Enter the patient full and permanent address and telphone number | Required Block |
| CMS 1500 Block 6 | Patient's Relationship to Insured ( we would like to select one from the subsequent options: Self/Spouse/Child/Other) | Tick mark whichever applicable to patient | Optional Block (If applicable) |
| CMS 1500 Block 7 | Insured's Address together with the Telephone Number | Enter Policy holder address and telephone number | Optional Block (If applicable) |
| CMS 1500 Block 8 | Reserved for National Uniform Claim Committee use | ||
| CMS 1500 Block 9 (a to d) | 9 : Another insurance policy name for this patient, which covers the health care services of the patient - Other Insured's Name 9a : Another policy or group number which covers the health care services of the patient - Other Insured's policy or group number 9d: Another insurance Plan name or programme name which covers this health care services of patient. | Block 9, 9a and 9d must be entered, when CMS 1500 Block 11d is completed. | Optional Block (If applicable) |
| CMS 1500 Block 10a to 10c | Employement (Current or previous)/Auto Accident/Other Accident | Tick mark appropriate option | Optional Block (If applicable) |
| CMS 1500 Block 10d | Reserved for NUCC use | Leave Blank | |
| CMS 1500 Block 11 (a to d) | 11 Insured Policy Group or FECA Number 11a Insured DOB and Sex 11b Other Claim ID(Designated by NUCC) 11c Insurance plan or programme name 11d is there another health benefit plan ( If yes complete CMS 1500 Block 9, 9a and 9d) | If CMS 1500 Block 4 is completed: Then enter insured policy/group number, DOB, Sex(Male/Female), employer/school name and Insurance plan/programme name as displayed on the member insurance ID card. | Optional Block (If applicable) |
| CMS 1500 Block 12 | Patients or Authorized person's signature. | Enter "Signature on file". It indicates that patient or gurantors as signed a form to release medical information for entities who are all involved in medical billing cycle. | Required Block |
| CMS 1500 Block 13 | Insured's or Authorized person's signature | This CMS 1500 Block 13 should have a phrase "Signature on file". This is to point to the payer to pay the reimbursement of health care claims on to the provider. | Required Block |
| CMS 1500 Block 14 | Date of Current illness, injury or pregnancy | Enter the date of injury or illness occurred onset date and if it’s a pregnancy, then enter LMP (Last Menstrual period). | Required Block |
| CMS 1500 Block 15 | Other Date | If the previous date for the identical patient had same or similar illness, then key those dates during entering this Block. | Optional Block (If applicable) |
| CMS 1500 Block 16 | Dates Patient unable to work in current occupation (From and To date) | Enter the span of dates (from and to) when patient is employed and unable to figure in their current occupation | Optional Block (If applicable) |
| CMS 1500 Block 17 (a to b) | 17 Name of the referring provider or other service. Enter one of the Qualifiers: DN(Referring provider), DK(Ordering provider) and DQ(Supervising provider)) 17a Referring provider identification number. 17b Referring provider NPI number | If the service is referred by a referring physician then enter this CMS 1500 Block 17 (a to B) Note: 17a leave empty, because it isn't reported. | Optional Block (If applicable) |
| CMS 1500 Block 18 | Hospitalization span dates associated with current health care services (From and To) | Enter the admission and discharge dates, if patient identifies an inpatient stay. | Optional Block (If applicable) |
| CMS 1500 Block 19 | Additional Claim information | Reserved for Local Use, when procedures require additional information | Optional Block (If applicable) |
| CMS 1500 Block 20 | Outside Lab (yes or no) | Select appropriate by ticking(X) the suitable Block. If "yes", then it indicates the entity performed the diagnostic assay is other then the entity billing this service. If "no", then it indicates no purchased diagnostic tests are included on the claim. | Required Block when biling the diagnostic tests |
| CMS 1500 Block 21 | Diagnosis or Nature of illness or injury | Enter the diagnosis code as per ICD 10 CODE | Required Block |
| CMS 1500 Block 22 | Resubmission Code | Leave Blank | |
| CMS 1500 Block 23 | Prior Authorization Number | Enter the prior authorization number for the services which require prior approval. | Required Block (If applicable) |
| CMS 1500 Block 24a | Dates of service (From and to) | Enter the dates when the patient was treated | Required Block |
| CMS 1500 Block 24b | Place of Service | Enter the place of service codes from the lists, to point where the health care services rendered. | Required Block |
| CMS 1500 Block 24c | EMG (Emergency Indicator) | Leave Blank | |
| CMS 1500 Block 24d | Procedures, services or supplies (CPT/HCPCS and Modifiers) | Enter appropriate modifiers, procedures or supplies using HCPCS code when applicable | Required Block (If applicable) |
| CMS 1500 Block 24e | Diagnosis pointer | Enter the dianosis code letter(A to L) from CMS 1500 Block 21 that applies to the procedure code indicated. | Required Block |
| CMS 1500 Block 24f | $ Charges | Enter the prices of each line in dollar amount. | Required Block |
| CMS 1500 Block 24g | Days/units (It is a measures of medical services, such as the number of hospital days, pints of blood, kidney dialisis treatments, etc.) | Note: Don't leave blank, because the units should be atleast entered as 1. | Required Block |
| CMS 1500 Block 24h | EPSDT/Family plan | Leave Blank | |
| CMS 1500 Block 24i | ID Qualifier | Leave Blank | |
| CMS 1500 Block 24j | Rendering Provider ID# | Enter the treating provider NPI number | Required Block |
| CMS 1500 Block 25 | Federal Tax ID number (SSN and EIN) | Enter the Federal Tax ID number assigned by the federal to doctors and hospitals for tax purposes. (Format is 3-2-4) | Required Block |
| CMS 1500 Block 26 | Patient Account Number | Patient Account number also called as encounter number. Enter the encounter number given by doctor or hospital for each and every patient's medical visit. | Required Block |
| CMS 1500 Block 27 | Accept Assignment (Yes or No) | Check the block with X. If its "yes" then provider agrees to simply accept the assignment of payers benefit. | Required Block |
| CMS 1500 Block 28 | Total Charge | Enter overall charges of the services | Required Block |
| CMS 1500 Block 29 | Amount paid | Enter overall amount paid by patient and/or other insurances for this service. | Required Block |
| CMS 1500 Block 30 | Reserved for NUCC use | Leave Blank | |
| CMS 1500 Block 31 | Signature of Physician or Supplier including degrees or credentials | Enter the signaute of physician or Supplier (Note: Stamped signatures are accepted) | Required Block |
| CMS 1500 Block 32 | Service Facility location information | Enter name, address of the place where the health care services delivered. | Required Block |
| CMS 1500 Block 32a | National Provider Identifier (NPI) | Enter the NPI number of the facility | Required Block |
| CMS 1500 Block 32b | ID Qualifier and PIN | Leave Blank (eff 05/23/2008 it's to not be reported) | |
| CMS 1500 Block 33 | Billing provider information and phone number | Enter name, address and number of the billing provider | Required Block |
| CMS 1500 Block 33a | NPI of the billing provider | Enter the NPI number of the billing provider | Required Block |
| CMS 1500 Block 33b | ID Qualifier and PIN | Leave Blank (eff 05/23/2008 it's to not be reported) |
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