Item 1

Check the Medicare Box.

Item 1a

Patient's Medicare number.

Item 4

Insured's name if Medicare is not primary. Leave blank if Medicare is primary. May have "SAME" when insured is the patient.

These are situational if Medicare iss not primary. For Electronic claims “SAME” is not acceptable.

Item 2

Patient's name - last name, first name, middle initial - must be as it appears on the Medicare Card.

Item 3

Date of birth - 8 digits - MM DD YYYY entered into spaces and appropriate box checked for sex.

Item 5

Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP codeand phone number.

Telephone number field not available in this format.

Item 6

Check the appropriate box for patient's relationship to insured when item 4 is completed.

Item 7

Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.

These are situational if Medicare is not primary. For Electronic claims “SAME” is not acceptable.

Telephone number field not available in this format.

Item 8

Leave blank.

Patient status field is not available in this format.

Item 9

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

Items 10a - 10c

Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

Items 11

If Medicare is primary, enter the word "NONE". If Medicare is secondary, enter the insured's policy or group number and proceed to items 11a through 11c. This field is required on a paper claim.

Item 9a

Policy number and or group number of the Medigap insured preceded by "MEDIGAP", "MG", or "MGAP."

Item 11a

Enter the insured's birth date and sex, if different from item 23.

Item 9b

Leave blank.

ANSI 5010 - This segment has been deleted.

Item 11b

Enter employer's name, if applicable. If there is a change in the insured's status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Form version 02/12: provide this information to the right of the vertical dotted line.

This field is not available in this format.

Item 9c

Leave blank if item 9d is completed. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card.

This field is not available in this format.

Item 11c

Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item 11.

Item 9d

Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier(ID).

Item 10d

Patient’s Medicaid number - If patient is not enrolled in Medicaid, leave blank.

Not Needed - Medicaid automatically crosses over.

Item 11d

Leave blank - this is not required by Medicare.

This field is not available in this format.

Item 12

The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Chapter 1, “General Billing Requirements.” If the patient is physically or mentally unable to sign, a representative specified in chapter 1, may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement.

NOTE: This can be “Signature on File” and/or a computer generated signature.

The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Note: The signature date field is not available in this format

Item 13

Enter either a patient’s or authorized person’s signature and date or enter “Signature on File” (SOF).

Item 14

Enter the date of the current illness, injury or pregnancy. For Chiropractic services, enter the date of the initiation of the course of treatment.

*Use if different information given at the claim level

Item 15

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 16

If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.

Item 17

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:

Qualifier Provider Role

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the dotted vertical line on item 17.

Item 17a

This block is not used after May 23, 2008.

This is not used after May 23, 2008.

Item 18

Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Item 17b

Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.

Item 19

Enter applicable dates (either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date), dosage, global surgery period, or other narrative information. All information listed in Item 19 and its electronic equivalent is situational.

Item 20

Enter the acquisition price under “$ Charges” if the “Yes” box is checked. A “Yes” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “No” check indicates that no anti-markup tests are included on the claim. When Yes is annotated, Item 32a shall be completed.

When submitting a PS1 segment, the facility information must also be in either loop 2310D or 2420C.

Item 21

The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)
• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Note: Up to eight diagnosis codes may be entered in priority order on electronic claims. Do not use decimal points.

ANSI 5010 - In addition: Up to 12 diagnoses may be entered.

Item 22

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 23

Leave blank or enter one of the following items as applicable:

• Quality Improvement Organization (QIO) prior authorization number
• Seven-digit Investigational Device Exemption (IDE) number when used in a clinical trial
• NPI of Home Health Agency or Hospice facility when Care Plan Oversight is billed
• Ten-digit CLIA number when lab services are billed
• For ambulance claims, enter the ZIP code of the point-of-pickup for the loaded ambulance trip

Item 24a

Enter the date of service - 6 digits (MMDDYY) or 8-digit (MMDDYYYY) date for each procedure or service.

Item 24b

Enter the appropriate two-digit place of service (POS) code to identify where the item is used or the service is performed.

Item 24c

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 24d

Enter the procedure code and up to four applicable modifiers.

Item 24e

This is a required field. Enter the diagnosis code reference letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis.

Item 24f

Enter the charge for each listed service. Note: Nonparticipating providers may not exceed the limiting charge fee for each service.

Item 24g

Enter the number of days or units. For anesthesia, convert hours into minutes, if necessary, and enter the total minutes required for the procedure.

Item 24h

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 24i

This field should be blank on all claims received after May 23, 2008. Exception: Providers who have terminated their Medicare provider numbers and were never assigned an NPI. The 1C qualifier must be in this field and there must be a comment in block 19 that this is a submission from a terminated provider.

This is only used when the exception is met and there are comments in the narrative field that the submission is from a terminated provider.

Item 24j

Enter the rendering provider’s NPI in the unshaded portion.

Item 25

Enter the Federal Tax ID (Employer Identification Number or Social Security Number) of the provider and check the appropriate box.

Item 26

Enter the patient's account number.

Item 27

Check the appropriate box to indicate whether the provider accepts assignment of Medicare benefits.

Item 28

Enter the total charges for the services.

Item 29

Enter the total amount that the patient paid for covered services only.

Item 30

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 31

Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

Item 32

Enter the name and complete address including the ZIP code of the facility where the services were rendered. If the supplier is a certified mammography screening center, enter the six-digit FDA approved certification number.

Item 33

Enter the provider’s billing name, address, ZIP code and telephone number.

Item 32a

Enter the NPI of the service facility. This is a conditional field. There should be nothing in this field unless there is a purchased test as listed in Item 20. The NPI of the provider from whom the test was purchased will be listed if this is the case.

Item 32b

Effective May 23, 2008 this field is not to be reported.

Effective May 23, 2008 this field is not to be reported.

Item 33a

Enter the NPI of the billing provider or group.

Item 33b

Item 33b is not generally reported. However, for some Medicare policies you may be instructed to use this item; direction as to how to use this item will be in the instructions you received regarding the specific policy, if applicable.

Effective May 23, 2008 this field is not to be reported.