INSTRUCTIONS FOR COMPLETING THE CMS 1500 CLAIM FORM

A CMS 1500 form is commonly used in private practice behavioral health care to bill Medicare carriers and insurance providers for reimbursement of eligible patient services. This form must be completed each time you submit an insurance claim. While you can submit it by mail, electronic submissions are often allowed for faster processing.

If you're new to filling out this form, continue reading to understand the CMS 1500 claim form instructions and learn how to avoid frequent errors.

Importance of Accurate CMS-1500 Submission

The CMS 1500 form contains approximately 33 fields, but not all fields are necessary for every patient or service type. Some fields may be left blank based on different factors, as each patient's coverage and service requirements vary. Mistakes or omissions can lead to financial loss, delays in processing, or denial of reimbursement. Errors will require correction and resubmission, impacting your profit margin. Mastering the proper completion and submission of billing forms can enhance your reimbursement rate and reduce complications.

Required Information for CMS 1500 Form

Insurance Details

The initial steps on the CMS 1500 involve entering insurance coverage information:

·???????? Coverage: Indicate the applicable health insurance type, such as Medicare.

·???????? Insured’s ID Number: Provide the insured’s ID number and ensure it matches the name on step 4. This is mandatory.

Patient and Insured Information

Next, provide specific information about the patient and, if applicable, the insured person:

·???????? Patient’s Name, Birth Date, and Gender: Enter the patient's full name, birth date (MM/DD/CCYY format), and gender.

·???????? Insured’s Name: List the insured’s name as in step 2.

·???????? Patient’s Address and Phone Number: Provide the patient's address and phone number without punctuation. Use a hyphen for a nine-digit ZIP code only.

·???????? Patient’s Relationship to Insured: Indicate the relationship between the patient and the insured based on steps 2 and 4.

·???????? Insured’s Address and Phone Number: Enter the insured’s address unless it’s the same as the patient's. If so, write “SAME.” Complete this after steps 4 and 11.

·???????? Patient Status: Check the appropriate boxes for the patient’s student, employment, and marital status.

Other Insured Information

Steps 9-13 focus on details about any other insurance the patient might have:

·???????? Other Insured’s Name: If applicable, list the name of the person covered under another payer.

·???????? Other Insured’s Policy/Group Number: Provide the policy or group number if there is additional insurance.

·???????? Other Insured’s Date of Birth: Enter the date of birth and mark gender if known.

·???????? Other Insured’s Employer/School: List the employer or school name if applicable.

·???????? Other Insured’s Insurance Plan/Program Name: Provide the insurance company or program name.

·???????? Condition Related to Employment/Accident: Indicate if the patient’s condition is related to employment or any accident. If so, include the state postal code for auto accidents.

·???????? Reserved for Local Use: Leave this field blank.

·???????? Insured’s FECA Number/Policy Group: Enter the insured’s policy or group number as per their healthcare ID card.

·???????? Insured’s Gender and Date of Birth: Include this information if it differs from step 3.

·???????? Employer/School Name: Provide this information if applicable.

·???????? Insurance Plan/Program Name: Include the insurance company or program name.

·???????? Other Health Benefit Plans: Indicate if there is another insurance plan involved.

·???????? Patient’s/Authorized Person’s Signature: The patient must sign and date the claim if authorizing the release of medical information and payment to the provider.

·???????? Insured’s/Authorized Person’s Signature: Use a signature on file (SOF) if applicable for authorizing payment to the provider.

Provider Information

Fields 14-23 are related to the provider's details:

·???????? Dates Patient Unable to Work: Complete this if the patient is eligible for worker’s compensation or disability benefits.

·???????? Referring Physician’s Name and ID Number: Provide the referring physician’s name and CMS-assigned seven-digit UPIN.

·???????? NPI: Enter the National Provider Identifier (NPI) for the referring provider.

·???????? Hospitalization Dates: Include dates if the claim involves inpatient services.

·???????? Reserved for Local Use: Enter “IOP” if billing for intensive outpatient programs.

·???????? Outside Lab/Charges: Include any charges from external labs.

·???????? Diagnosis or Nature of Illness/Injury: List an ICD-10 diagnosis code to the highest specificity and the services provided. Write “0” in the ICD Ind. field.

·???????? Medicaid Resubmission Code/Original Reference Number: Enter the reference claim number for resubmissions.

Hospitalization and Billing Information

This section includes details about the patient’s procedure and billing:

·???????? Dates of Service: List the “from” and “to” dates in MM/DD/YY format. For single-day services, use the “from” field.

·???????? Place of Service: Enter the appropriate place of service code.

·???????? Procedures, Services, or Supplies CPT/HCPCS: List the CPT or HCPCS codes and modifiers, if applicable, for each service.

·???????? Diagnosis Pointer: Indicate the diagnosis code reference number related to the procedures and service dates.

·???????? Charges: Enter the billed charges for each service.

·???????? Days or Units: Specify the number of days or units related to step 24a.

·???????? EPSDT Family Plan: Mark this field if the service was part of an EPSDT panel.

·???????? ID Qual.: Complete if there is no NPI, including the qualifier and identifying number.

·???????? Rendering Provider ID. #: Add the NPI number.

·???????? Federal Tax ID Number and Type: Enter the SSN or EIN and indicate the type used.

·???????? Patient’s Account Number: Provide the patient’s unique account number.

·???????? Accept Assignment: Mark to show whether your practice accepts Medicare benefit assignments.

·???????? Total Charge: List the total charge for the claim.

·???????? Amount Paid: Enter the amount the patient paid.

·???????? Balance Due: Provide the remaining balance.

·???????? Signature of Physician or Supplier: Add your signature, credentials, and the date.

·???????? Name and Address of Facility: Include the name and address where services occurred.

·???????? NPI: Enter the NPI of the service facility.

·???????? Physician’s/Supplier's Billing Name, Address, and Phone Number: Provide billing information.

·???????? PIN: Enter the NPI of the billing provider or group.

In Conclusion, Completing the CMS 1500 form accurately can be challenging if you’re not familiar with the required details. The CMS 1500 claim form instructions highlight necessary information, fields that may be left blank, and items relevant to your service or patient.