Corporate

CMS 1500 Claim Form Instructions Tool

To view instructions, hover over each field.

Item 1

Item 1

Check the Medicare Box.

Loop 2000B -SBR09 - MB qualifier for Medicare
Item 1a

Item 1a

Patient's Medicare number.

Loop 2010BA -NM109
Item 4

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.

Loop 2330A -NM103 - Insured’s last name
NM104 - Insured’s first name
NM105 - Insured’s middle name
NM107 - Insured’s name suffix
Item 2

Item 2

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

Loop 2010BA -NM103 - Last name
NM104 - First name
NM105 - Middle name or initial
NM107 - Name suffix
Item 3

Item 3

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

Loop 2010BA -DMG01 - D8 qualifier
DMG02 - Birth date - MM DD YYYY
DMG03 - Gender (F or M)
Item 5

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.

Loop 2010BA -N301 - Address line 1
N302 - Address line 2 if needed
N401 - City name
N402 - State code
N403 - Postal or ZIP code

Telephone number field not available in this format.

Item 6

Item 6

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

Loop 2000B -SBR02 - 18 qualifier for Medicare
Loop 2320 -Only required if Medicare is secondary.
Item 7

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.

Loop 2330A -N301 - Insured's ddress line 1
N302 - Insured's address line 2 if needed
N401 - Insured's city name
N402 - Insured's state code
N403 - Insured's Postal or ZIP code

Telephone number field not available in this format.

Item 8

Item 8

Leave blank.

Patient status field is not available in this format.

Item 7
Item 9

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.

Loop 2330A -NM103 - Medigap Insured’s last name
NM104 - Insured’s first name
NM105 - Insured’s middle name
NM107 - Insured’s name suffix
Items 10a - 10c

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.

Loop 2300 -CLM11-1 - Employment related (EM qualifier)
CLM11-2 - Auto Accident related (AA qualifier)
CLM11-3 - Other Accident related (OA qualifier)
CLM11-4 - Auto Accident State code
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.

Loop 2320 -SBR03 - Primary Group or policy number
Loop 2330A -NM109 - Other insured identifier
Loop 2320 -SBR09 - Claim filing indicator code
Loop 2000B -SBR05 - Insurance type code
Item 9a

Item 9a

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

Loop 2330A -NM109 - Medigap policy number
Loop 2320 -Insured's Group or Plan number
Item 11a

Item 11a

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

Loop 2320 -DMG01 - D8 qualifier
Item 9b

Item 9b

Leave blank.

Loop 2320 -DMG01 - DB qualifier
DMG02 - Birth data - YYYY MM DD
DMG03 - Gender (F or M)

ANSI 5010 - This segment has been deleted.

Item 11b

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

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.

Loop 2330B -NM101 - PR qualifier
NM103 - Employer name or school name
Item 11c

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.

Loop 2320 -SBR04 - Insured group name
Item 9d

Item 9d

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

Loop 2330B -NM109 - Medigap COBA Medigap-Based Identifier number
NM103 - Medigap Plan name
Loop 2320 -SBR04 - Medigap group name
Item 10d

Item 10d

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

Not Needed - Medicaid automatically crosses over.

Item 11d

Item 11d

Leave blank - this is not required by Medicare.

This field is not available in this format.

Item 12

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.

Loop 2300 -CLM10 - Patient's signature source code
CLM09 - Release of Information code

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

Item 13

Item 13

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

Loop 2300 -CLM10 - Patient's signature source code
CLM08 - Certification Indicator
Loop 2320 -OI03 - Benefits assignment
Item 14

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.

Loop 2300 -DTP01 - 439 qualifier
DTP03 - Accident Date
DTP01 - 431 qualifier
DTP03 - Date of current illness or injury
Loop 2400 -DTP01 - 431 qualifier*
DTP03 - Date of current illness or injury *
Loop 2300 -DTP01 - 454 qualifier
DTP03 - Initial treatment date
Loop 2400 -DTP01 - 454 qualifier*
DTP03 - Initial treatment date*

*Use if different information given at the claim level

Item 15

Item 15

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 16

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.

Loop 2300 -DTP01 - 360 qualifier
DTP03 - Disability "from" date
DTP01 - 361 qualifier
DTP03 - 361 qualifier
Item 17

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.

Loop 2310A -NM101 - DN qualifier
NM103 - Referring provider's last name
NM104 - Referring provider's first name
NM105 - Referring provider's middle name
 NM107 - Referring provider's name suffix
 ~OR loop 2420F or 2420E, if different from the provider reported at the claim level~
Loop 2420F -NM101 - DN qualifier*
NM103 - Referring provider's last name*
 NM104 - Referring provider's first name*
 NM105 - Referring provider's middle name*
Loop 2420E -NM101 - DK qualifier
NM103 - Ordering provider's last name
 NM104 - Ordering provider's first name
NM105 - Ordering provider's middle name
Item 17a

Item 17a

This block is not used after May 23, 2008.

This is not used after May 23, 2008.

Item 18

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.

Loop 2300 -DTP01 - 435 qualifier
DTP03 - Related hospital admission date
DTP01 - 096 qualifier
DTP03 - Related hospital discharge date
Item 17b

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.

Loop 2310A -NM109 - NPI of the referring physician
~OR~
Loop 2420FNM109 - NPI of the referring physician
Loop 2420ENM109 - NPI of the referring physician
Item 19

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.

Loop 2300 - Extra Narrative Data
Loop 2400 - Extra Narrative Data
Loop 2300 - DTP01 - 304 qualifier
 DTP03 - Date last seen
Loop 2400 - DTP01 - 304 qualifier
 DTP03 - Date last seen
Loop2310D - NM101 - DQ qualifier
 NM109 - Supervising Provider ID
Loop 2420D - NM108 - DQ qualifier
 NM109 - Supervising Provider ID
Loop 2300 - CRC01 - IH qualifier
 CRC03 - Homebound indicator
Loop 2300 - REF01 - P4 qualifier
 REf02 - Demonstration project identifier
Loop 2300 - DTP01 - 090 qualifier
 DTP03 - Date assumed care
Loop 2300 - DTP01 - 091 qualifier
 DTP03 - Date relinquished care
Loop2310C - NM108 - QB qualifier
 NM109 - Purchased Service Provider ID
Loop 2420B - NM108 - QB qualifier
 NM109 - Purchased Service Provider ID
Loop 2300 - DPT01 - 455 qualifier
 DPT03 - Last X-ray date
Loop 2400 - DPT01 - 455 qualifier
 DPT03 - Last X-ray date
Loop 2400 - DPT01 - 455 qualifier
 DPT03 - Last X-ray date
ANSI 5010 - In addition to those listed above:
Loop 2310D - NM108 - DQ qualifier
 NM109 - Supervising Provider ID
Item 20

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.

Loop 2400 -PS102 - Anti-markup Service Charge Amount

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

Item 21

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.
Loop 2300 -HI01-1 - BK qualifier
HI01-2 - Primary diagnosis code
HI02-1 - BF qualifier
HI01-2 - Diagnosis code
HI01-3 - BF qualifier
HI01-1 - Diagnosis 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

Item 22

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 23

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
Loop 2300 - REF01 - G1 qualifier
 REF02 - QIO Prior Authorization
Loop 2300 - REF01 - LX qualifier
 REF02 - IDE Number
Loop 2300 - REF01 - 1J qualifier
 REF02 - Care Plan Oversight Number
Loop2300 - REF01 - X4 qualifier
 REF02 - CLIA certification number
Loop 2400 - REF01 - X4 qualifier
 REF02 - CLIA certification number
Loop 2400 - REF01 - F4 qualifier
 REF02 - Referring CLIA number
ANSI 5010 - In addition to those listed above:
Loop 2310E - NM101 - PW qualifier
 NEM03 - Ambulance Organization name
 N301 - Ambulance Pick Up address line 1
 N302 - Ambulance Pick Up address l line 2 if needed
 N401 - Ambulance Pick Up city name
 N402 - Ambulance Pick Up state code
 N403 - Ambulance Pick Up ZIP code
Loop2310F - NM101 - 45 qualifier
 NM103 - Ambulance Organization name
 N301 - Ambulance Drop Off address line 1
Item 24a

Item 24a

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

Loop 2400 -DTP01 - 472 qualifier
DTP02 - D8 if a single date of service
DTP02 - RD8 if a range of dates
DTP03 - Date of Service
Single date - MMDDYYYY
Range - MMDDYYYY - MMDDYYYY
Item 24b

Item 24b

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

Loop 2300 -CLM05-1 - Facility Type Code
Loop 2400 -SV105 - POS code if different than on claim level
Item 24c

Item 24c

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 24d

Item 24d

Enter the procedure code and up to four applicable modifiers.

Loop 2400 -SV101-1 - HC qualifier
SV101-2 - Procedure code
SV101-3 - Modifier 1
SV101-4 - Modifier 2
SV101-5 - Modifier 3
SV101-6 - Modifier 4
Item 24e

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.

Loop 2400 -SV107-1 - Diagnosis pointer
SV107-2 - Diagnosis pointer
SV107-3 - Diagnosis pointer
SV107-4 - Diagnosis pointer
Item 24f

Item 24f

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

Loop 2400 -SV102 - Line item charge amount
Item 24g

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.

Loop 2400 -SV103 - UN qualifier
SV104 - Number of units
SV103 - MJ qualifier
SV104 - Number of minutes
Item 24h

Item 24h

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 24i

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.

Loop 2310B -REF01 - 1C qualifier
Loop 2420A -REF01 - 1C qualifier

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

Item 24j

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

Loop 2310B -NM101 - 82 qualifier
NM108 - XX qualifier
NM109 - Rendering provider's NPI
Loop 2420A -NM101 - 82 qualifier
NM108 - XX qualifier
NM109 - Rendering provider's NPI
Item 25

Item 25

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

Loop 2010AA -NM101 - 85 qualifier
NM109 - Billing provider identifier
NM101 - 87 qualifier
MN109 - Pay-to-provider identifier
OR
Loop 2010AB -NM101 - 34 qualifier
NM108 - Social Security Number
NM101 - SY qualifier
NM108 - Employer ID number
Loop 2010AA -REF01 - EI qualifier
REF02 - Employer ID Number
OR
Loop 2010AB -REF01 - EI qualifier
REF02 - Employer ID Number
Item 26

Item 26

Enter the patient's account number.

Loop 2300 -CLM01 - Account number (up to 20 characters)
Item 27

Item 27

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

Loop 2300 -CLM07 - Assignment code
A - Assigned
B - Assignment on Clinical Lab Services Only
C - Not assigned
P - Patient refuses to assign benefits
Item 28

Item 28

Enter the total charges for the services.

Loop 2300 -CLM02 - Total charges
Item 29

Item 29

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

Loop 2300 -AMT01 - F5 qualifier
AMT02 - Patient paid amount
Item 30

Item 30

Leave blank. Not required by Medicare.

Leave blank. Not required by Medicare.

Item 31

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.

Loop 2320 -CLM06 - Provider signature indicator
Y - Valid signature on file
N - No valid signature on file
Item 32

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.

Loop 2310D - NM101 - FA qualifier
 NM103 - Facility Name
 N301 - Facility Address
 N401 - Facility City
 N402 - Facility State
 N403 - Facility ZIP Code (nine digits)
OR - if different than claim level
Loop 2420C -NM101 - FA qualifier
 NM103 - Facility Name
 N301 - Facility Address
 N401 - Facility City
 N402 - Facility State
 N403 - Facility ZIP Code (nine digits)
If Mammography Center:
Loop 2300 -REF01 - EW qualifier
 REF02 - Mammography FDA number
Loop 2400REF01 - EW qualifier
 REF02 - Mammography FDA number
ANSI 5010 - In addition to those listed above:
Loop2310C - NM101 - FA qualifier
 NM103 - Facility Name
 N301 - Facility Address
 N401 - Facility City
 N402 - Facility State
 N403 - Facility ZIP Code (nine digits)
Item 33

Item 33

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

Loop 2010AA -NM101 - 85 qualifier
NM103 - Billing provider's last name or Organization name
NM104 - Provider's first name
NM105 - Provider's middle initial
NM107 - Provider's name suffix
N301 - Provider's address
N401 - Provider's city
N402 - Provider's State
N403 - Provider ZIP code (nine digits)
PER04 - Provider's telephone number
Item 32a

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.

ANSI 5010 -
Loop 2310C - NM108 - XX qualifier
NM109 - Facility NPI
Item 32b

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

Item 33a

Enter the NPI of the billing provider or group.

Loop 2010AA - NM108 - XX qualifier
NM109 - Provider NPI
Loop 2010AB - NM108 - XX qualifier
NM109 - Provider NPI
Item 33b

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.

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