CMS-1500 Form

Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied. Below is the downloadable CMS-1500 forms designed to facilitate successful claim submissions. Examples of claim forms and potential codes that may be appropriate when billing for Cathflo and related services are included as well.

Note: Select the appropriate billing code when filing all claims. Billing codes should be based on diagnosis and the services provided.

CMS-1500 Form (interactive PDF)
Example of CMS-1500 (PDF)

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How to complete the CMS-1500

The CMS-1500 is used by physicians, durable medical equipment suppliers, and other providers to bill Medicare, Medicaid, CHAMPUS, VACHAMPUS, Group Health Plan, FECA Black Lung, or other type of insurance. In rare instances, some insurance companies may request free-standing clinics and hospitals to submit charges with the CMS-1500 form.

All providers billing with the CMS-1500 must provide specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCFA Common Procedural Coding System (HCPCS). The number of services rendered and the charge for these services depends on the facility's charge master.

The following table lists instructions for completing a CMS-1500 form. Form fields are referred to as "blocks."

Block Code	Instruction
1	Indicate insurance type (eg, Medicare, Medicaid, CHAMPUS, VACHAMPUS, Group Health Plan, FECA Black Lung, or other type of insurance).
1a	If "Medicare," enter the patient's Medicare Health Insurance Claim Number (HICN) and suffix (eg, 011-01-0111-A), or other assigned patient insurance numbers.
2	Enter patient's last name, first name, and middle initial as it appears on his or her insurance card.
3	Enter the patient's date of birth and sex.
4	Leave this block blank if the patient's primary insurance is Medicare or Medicaid. If the patient has another primary insurance (such as an employee group health plan through a spouse), list the name of the insured party. If the patient is the holder of the insurance, enter the word "SAME."
5	Enter the patient's mailing address and telephone number. In the STATE field, enter the two-letter state abbreviation.
6	Check the box that corresponds to the relationship between the holder of the insurance policy and the patient.
7	Leave this block blank if block 4 contains the word "SAME." If block 4 contains other insurance holder information, enter the insurance holder's mailing address and telephone number.
8	Check the appropriate status for the patient.
9	If the patient has a MEDIGAP policy or other insurance and wishes to use this policy for coordination of benefits, enter the patient's last name, first name and middle initial. If block 9 is completed, complete block 13.
9a	Enter the policy number. If the policy in block 9 is a MEDIGAP policy, enter the word "MEDIGAP" before the policy number.
9b	Enter the enrollee's date of birth and sex.
9c	Leave blank and enter information on block 9d.
9d	Enter the enrollee's insurance plan name or insurer's unique identification number provided by the local Medicare Carrier.
10a, b, c	Check the appropriate boxes.
10d	Leave blank unless the patient has Medicaid. If the patient has Medicaid, enter the Medicaid number.
11	Ascertain the patient's primary insurance. If the insurance is primary over Medicare, enter the insurance name and complete blocks 11a11c. If there is no other insurance, enter "NONE."
11a	Enter the insured date of birth and sex if different than box 3.
11b	Enter the employer's name, if applicable. If the insured is retired, enter "RETIRED" before the date.
11c	Enter the name of the insurance plan.
11d	Leave this blank.
12	Have the patient or patient representative sign here. Most insurance companies, carriers, and intermediaries will accept a notation of "SIGNATURE ON FILE." For patients who assign benefits, maintain a record of these signatures for future audits.
13	Have the patient or patient representative sign here. Most insurance companies, carriers, and intermediaries will accept a notation of "SIGNATURE ON FILE." For patients who assign benefits, maintain a record of these signatures for future audits.
14	Enter date of current illness or injury.
15	Leave blank.
16	Consult your insurance representative to determine the correct completion. Complete if worker's comp. Leave blank if Medicare/Medicaid.
17	If the provider ordered the service, enter the provider's name. If the service is covered by Medicare, enter the referring provider's information.
17a	Enter the CMS-assigned NPI provider number. If one is not available use the UPIN number for the referring physician.
18	Complete this section if services are related to a hospitalization.
19	Leave blank.
20	Check the appropriate box and enter the cost. Indicate whether diagnostic tests are purchased under an arrangement with an outside vendor and billed for by the provider. Charges are subject to price limitations under Medicare.
21	Enter the ICD-9-CM codes that correspond to the patient's diagnoses. A maximum of four ICD-9-CM codes is allowed per form; list each code in order of priority. No description is necessary for these ICD-9-CM codes. As with all diagnoses, the codes must correspond to the documentation in the patient's chart.
22	Use only for Medicaid, otherwise leave blank.
23	If the service requires prior authorization (as it does with Peer-Review-Organizations), enter an authorization number, otherwise leave blank.
24	Only 6 lines are available for services. Enter each service on a separate line. Enter the beginning date of service (use the format mm dd yy). Enter the ending date of service. Enter the appropriate two-digit number for the location where the service was delivered. Enter the appropriate HCPC and modifier where necessary. Enter the appropriate diagnostic code that corresponds with this service as identified in block 21. Enter the charge for this service. Do not use punctuation (periods or dollar signs). Enter the total number of days or units of service. Leave this blank unless required by your insurance company. Leave this blank unless required by your insurance company. Leave this blank unless required by your insurance company. Enter the Carrier-assigned Provider Identification Number (PIN). If more than one provider is billing on this CMS-1500 form, use the PIN of the provider performing the service.
25	Enter the Federal Tax ID or Social Security Number of the group or person supplying the services. Do not use punctuation (dashes between numbers).
26	Enter the patient's identification number as assigned by the group providing the services.
27	If the provider accepts the assignment of Medicare benefits, check "yes"; if not, check "no."
28	Enter the total charges for service(s). Do not use punctuation (periods or dollar signs).
29	For Medicare, enter the total amount to be paid for covered services.
30	Leave this blank unless instructed otherwise by your insurance company.
31	Enter the signature and date of the provider or representative completing this claim.
32	Enter the name and address of the facility where the services were rendered only if different from the address in block 33.
33	Enter the information and UPIN of the provider who is to be paid for the services performed.

The submission criteria for completing the CMS-1500 form may vary. To ensure all local submission criteria are met, providers should contact their representative before submitting claims.