Cms 1500 Flashcards

Upper right corner

Type of Insurance for this filing of claim

(payer you are sending this claim to)

Insured's I.D. Number (insurance being filed

on this claim form) Note: if pt has unique

ins ID number, then put that here

Patient's Name (Last, First, Middle Initial) -

Must be same as on insurance card!

Can use commas to separate names.

Patient's Birth Date (8-digit format, no

punctuation used) MMDDYYYY

Insured's Name (Last, First, Middle Initial) -

as on insurance card (can use commas)

Patient's Address (use no punctuation

except hyphen for 9 digit zip code)

Patient Relationship to Insured

Insured's Address (no punctuation

except hyphen for 9 digit zip code)

Secondary Ins Information:

9.Other Insured's Name (Last, First, MI)

a. Other Insured's Policy or Group No

b. and c. (reserved for NUCC use)

d. Insurance Plan Name or Program Name

Note: this info is for secondary insurance

on current claim

Patient's condition caused by:

Check all boxes appropriate to tell what pt's

condition is related to. Not checking

anything could cause claim to be rejected

or denied

Insured's Policy Group or FECA Number

a. Insured's Date of Birth, sex

b. Other claim ID

c. Insurance Plan Name or Program Name

d. Is there another health benefit Plan?

If this is checked yes, then complete

items 9, 9a, 9d

Authorization for release of PHI to process claim. NOTE: this block ALSO functions as

assignment of benefits for Medicare,

Tricare, and Champva (gov't benefits).

If completed with SOF, must include date

that signature is on file.

Signature for assignment of benefits,

private-pay insurances. If completed

with SOF, must include date that signature

is on file.

Patient and Insured Information

Physician or Supplier information

Date of current illness, injury, or

pregnancy LMP

Note: if there is date here, must be 3-digit

qualifier after dotted line. For example,

LMP would be 484, date of current

illness, 431.

Other date that applies to illness. Needs

qualifier if used.

Dates patient unable to work in current

occupation. If still in hospital, only From

date will be completed. Generally used if

this is worker comp claim, or if current

claim reflects services due to

hospitalization.

Name of Referring Provider or other

source (First, Last, credential). Needs

qualifier before dotted line if used.

NPI of person in block 17 (Referring Provider).

If another number used, goes in shaded

area with qualifier listed first.

Use this field when billing for purchased lab

services by entering an X in “YES. This is if

another lab furnishes services but you are charging for them. You must put the amt

lab charges as well. Medicare does not allow mark-ups for lab services. CLIA waived tests

are not included here. Put address in block

32 of laboratory who performs services.

Can put up to 12 DX codes here. Enter ICD

indicator of 9 for ICD-9-CM, or 0 for

ICD-10-CM used.

For resubmitted claim. Enter 7 or 8 to left of

line, original reference number from

original claim to right of line. (7 - resubmit

original, 8 void/cancel original)

Enter Payer Authorization Number for a

pre-authorized service

Date of Service info. Do not need to put

same date twice in same line.

Enter Place of Service 2-digit code.

Check with payer to see if emergency

indicator is necessary. Otherwise,

leave blank.

Procedures, services, or supplies. Enter CPT/HCPCS code, up to 4 modifiers.

Only 6 service lines can be entered per

form. Gray lines are for special

additional info.

DX Pointer: Properly link your dx codes

to services here!! Can use up to 4 letters

to designate dx's that are appropriate.

List primary dx first.

List charge for service here

List days or units of service(s)

Put Y here for yes if service is EPSDT;

otherwise, leave blank.

Enter ID qualifier if you use a number other

than NPI in 24J. Put the non-NPI number

in the gray area in 24J, and put the ID

qualifier in 24I in the gray area.

Put rendering provider ID # here

Put Federal Tax ID number, check

appropriate box. NPI number does

NOT go here!

Put patient account number here

Accept assignment? Check yes or no. This

must be reported for all payers. Note:

box 13 is patient's permission, this

box is provider's acceptance.

Put total charges of all services in 24F

column.

Put amount paid by patient for COVERED

SERVICES (i.e., copay), and/or for

secondary claims, amount paid by

primary insurance or other payers.

In 5010A1, this info doesn't exist. Therefore,

only need to put on form if you are sending

paper claim that won't be converted to

electronic format. Can then put in SOF

or signature of physician or supplier

with credentials listed.

Reserved for NUCC use

Service Facility Location Info

Must be used if put yes in block 20. This

must be external organization to the

billing provider.

Name, Address, City, State, Zip Code of

billing provider. Phone number

(no hyphens) in upper right space. Use

hyphen for 9 digit zip code. This should

ALWAYS be completed.

NPI of billing provider.

Non-NPI ID number

Only used if required by payer. Use 2 digit

qualifier in front of number to designate

what type of non-NPI number you are

using.

RED

10-pitch PICA. Also, form must be

completed in ALL CAPS per UCR

standards. (Universal Character

Recognition)

Many claim details can be entered in

block 19 under CMS guidelines, and

for requests from private payers. For

instance, if modifier 99 used, all the

additional modifiers may be listed

here per NUCC guidelines.