CMS 1500 Claim Form|Sample HCFA 1500 Claim Form|

The HCFA 1500 claim form, also known as CMS 1500 claim form as well. The CMS 1500 Claim Form is the uniform or standard claim form used by a provider or supplier to bill Medicare and DMERCs (durable medical equipment regional carriers) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The NUCC- National Uniform Claim Committee is authorized and responsible for the design and maintenance of the CMS1500 forms.

Sample HCFA 1500 ClaimForm-CMS 1500 Form

cms 1500 form field descriptions
HCFA 1500 Claim Form- Image Source www.cms.gov

HCFA 1500 Claim Form Box Locator

BoxDescriptionRequired/Not Required
Box 1Type of InsuranceN
Box 1aPatient’s insurance policy  ID NumberY
Box 2Patient’s NameY
Box 3 Patients’s Date of Birth and SexY
Box 4Patient’s Name (Last-First-Middle Name)N
Box 5Patient’s AddressY
Box 6Patient’s Relation with insured ( Self/Spouse/Child/other)N
Box 7Insured Person Addressrequired when insured name updated in collumn 4
Box 8Patient Status( Married/Single/Employed/Student/Other)N
Box 9Other Insured’s NameN
Box 9aOther Insured’s Policy or group numberN
Box 9bOther Insured’s DOBN
Box 9cOther Insured’s Employer’s name/School NameN
Box 9dOther Insured’s Plan NameN
Box 10APatient’s condition Related to EmploymentN
Box 10BPatient’s condition Related to Auto AccidentAs per condition
Box 10CPatient’s condition Related to other AccidentAs per condition
Box 10dReserve for local useN
Box 11Insured’s Policy/ Group/ FECA NumberN
Box 11aInsured’s DOB/ SexN
Box 11bEmployer Name or School Name)N
Box 11cInsurance Plan Name or programe NameN
Box 11dIs there another health benefit plan?N
Box 12Patient’s or Authorized Person’s SignatureY
Box 13Insured’s or Authorized Person’s SignatureAs per condition
Box 14Date of Current Illness, Injury, Pregnancy (LMP)N
Box15If Patient Has Had Same or Similar Illness give 1st dateN
Box 16Dates Patient is Unable to Work in Current OccupationN
Box 17Name of Referring Provider or SourceAs per condition
Box 17aOther idN
Box 17bReferring/Ordering Provider NPIAs per condition
Box 18Hospitalization Dates Related to Current ServicesAs per condition
Box 19Additional Claim Information (earlier reserved for local use)N
Box 20Outside Lab ChargesN
Box 21Diagnosis or Nature of Illness or Injury (dx codes)Y
Box 22Resubmission and/or Original Reference NumberAs per condition(6 – Corrected Claim,7 – Replacement of prior claim,8 – Void/cancel of prior claim)
Box 23Prior Authorization NumberNo
Box 24Shaded Area Above. Use this area for and NDC/UPN information. As per condition
Box 24aDate of ServiceY
Box 24bPlace of ServiceY
Box 24cEMGIn emergency case enter Y otherwise N
Box 24dProcedures, Services, or SuppliesCPT or HCPCS code and modifier
Box 24eDiagnosis PointerY
Box 24fCharges or Billed AmountY
Box 24gDays or Units BilledY
Box 24hEPSDT/Family PlanN
Box 24iID QualifierN
Box 24jRendering Provider ID # (NPI)As per condition
Box 25Federal Tax ID or SSNY
Box 26Patient’s Account NumberN
Box 27Accept AssignmentAs per condition. Enter an X in the correct box noting if assignment is accepted
Box 28Total Chargey
Box 29Amount Paid As per condition
Box 30Reserved for NUCC Use (earlier
Balance Due)
N
Box 31Signature of Physician or Supplier Including Degrees or CredentialsY
Box 32Service Facility LocationAs per condition
Box 32aService Facility NPIN
Box 32bService Facility Other ID NumberN
Box 33Billing Provider Info and Phone NumberY
Box 33aBilling Provider NPI Y
Box 33bBilling Provider Other ID NumberN

The CMS 1500 form (HCFA-1500) is used to submit charges covered under Medicare Part B or for professional billing claims.

Image source and Information Reference www.cms.gov

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