Question

How do you complete a CMS-1500 Health Insurance Claim Form?

whats the proper way to complete a CMS-1500 Health Insurance Claim Form?

Answer 1

FOLLOW THESE TIPS TO HELP ENSURE PROPER SCANNING AND TIMELY PROCESSING:

Enter the data within the boundaries of the fields provided and ensure all information is aligned properly. Do not write between lines.

Type (in Arial or Times New Roman font) or print all information. Entries should be dark enough to be legible.

Use black ink only. Red and blue ink cannot be properly "read" by the scanning equipment.

Do not highlight the claim form or attachments. Highlighted information can become “blackedout” when scanned.

Do not submit claim forms with corrections, such as information written over correction fluid or crossed out information. If mistakes are made, complete a new form.

Capitalize alpha characters. Do not use special characters (e.g., dollar signs, decimals, dashes). Do not use commas to separate thousands.

Do not write or use staples on the bar-code area.

Do not use adhesive labels (e.g., address) or place stickers on the form. Do not use a rubber stamp in any fields on the form.

KEY:

R = REQUIRED | NR = NOT REQUIRED | S = SITUATIONAL, ONLY USE IF APPROPRIATE SPECIFIC TO CLAIM

1

TYPE OF HEALTH INSURANCE COVERAGE

R

Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

1A

INSURED ID NUMBER

R

List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.

2

PATIENT’S NAME

R

Enter the patient's last name, first name, and middle initial, if any. NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.

3

PATIENT’S BIRTH DATE/GENDER

R

Enter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.

4

INSURED’S NAME

R

Enter the insured's full last name, first name and middle initial. If the insured has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name.

5

PATIENT’S ADDRESS/TELEPHONE NUMBER

R

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 code and phone number.

6

PATIENT’S RELATIONSHIP TO THE INSURED

R

Select the appropriate box for patient’s relationship to the insured person.

7

INSURED’S ADDRESS/TELEPHONE NUMBER

S

Enter the insured person’s permanent mailing address (’patien

8

RESERVED FOR NUCC USE

NR

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

9

OTHER INSURED’S NAME

S

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

9a

OTHER INSURED’S POLICY OR GROUP NUMBER

S

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

9b

RESERVED FOR NUCC USE

NR

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

9c

RESERVED FOR NUCC USE

NR

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

9d

INSURANCE PLAN NAME OR PROGRAM NAME

NR

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

10

a - c

IS PATIENT’S CONDITION RELATED TO:

For 10a – 10c, required status is contingent upon a definitive “Yes” or “No” answer. If you are unsure, leave blank. 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. The state postal code, (i.e. MO) must be shown. Any item checked "YES" indicates there may be other insurance primary to Medicare. Primary insurance information must then be shown in item 11.

If you are unsure, leave blank.

10a

S

Select whether the patient’s condition is related to employment.

10b

S

Select whether the patient’s condition is related to an auto accident and enter the state in which the accident occurred. Use two-character abbreviation.

10c

S

Select whether the patient’s condition is related to any other type of accident.

10d

CLAIM CODES (DESIGNATED BY NUCC)

S

11

INSURED’S POLICY GROUP OR FECA NUMBER

NR

Enter the subscriber’s group number.

11a

INSURED’S DATE OF BIRTH, GENDER

NR

Enter the subscriber’s date of birth using the eight-digit date format (MM/DD/CCYY) and

select the subscriber’s gender.

11b

OTHER CLAIM ID

NR

.

11c

INSURANCE PLAN NAME OR PROGRAM NAME

NR

Enter the subscriber’s insurance plan name, include name of state.

11

IS THERE ANOTHER HEALTH INSURANCE BENEFIT PLAN?

R

Select whether there is another health insurance plan. Remember, if there is another health insurance plan, you will need to complete fields.This information is necessary to coordinate benefits with other insurance companies.