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CMS-1500 (HCFA)

Applicable Services

Required Reports

Forms & Attachments

Filling out the Form

Instructions

Service

Regulation

Physician Services

§ 127.201 Medical Bills – Standard Forms 

Laboratory / Pathology

DME

PT / OT

Dispensed Pharmaceuticals

CMS-1500 Medical Bill

Required Documents

Physicians

Office notes

DME

Medicare/HCPC code, certificate of medical necessity

Anesthesia

ASA code, base/time units, anesthesia record

Radiology

Reports

Laboratory

Test results

PT / OT

Daily treatment records/notes with physician referral

Chiropractor

Treatment notes

Pharmacy

NCD#, amount dispensed, RX#

Items 0 through 10

Items 11 through 20

Items 21 through 33

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

California Workers' Compensation Instructions

0

CARRIER NAME AND ADDRESS

R

Enter the Name and Address of the Payer to whom this bill is being sent.

1

MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA, BLACK LUNG, OTHER

R

Enter 'X' in Box Other.

1a

INSURED’S I.D. NUMBER

R

Enter the patient's Social Security Number. If the patient does not have a Social Security Number, enter the following 9 digit number: '999999999'.

2

PATIENT’S NAME (Last Name, First Name, Middle Initial)

R

3

PATIENT’S BIRTH DATE, SEX

R

4

INSURED’S NAME (Last Name, First Name, Middle Initial)

R

Enter the name of the Employer.

5

PATIENT’S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

R

6

PATIENT RELATIONSHIP TO INSURED

R

Enter 'X' in Box 'Other'.

7

INSURED'S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

S

Required when the bill is the first indication of the work related incident and the claim number is not entered in Box 11. Enter the physical address where the employee works.

8

RESERVED FOR NUCC USE

N

9

OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)

S

Required if applicable.

9a

OTHER INSURED'S POLICY OR GROUP NUMBER

S

Required if applicable.

9b

RESERVED FOR NUCC USE

N

9c

RESERVED FOR NUCC USE

N

9d

INSURANCE PLAN NAME OR PROGRAM NAME

S

Required if applicable.

10a

IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT

R

Enter 'X' in Box 'YES'.

10b

IS PATIENT'S CONDITION RELATED TO: AUTO ACCIDENT _ PLACE (State)

N

10c

IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT

N

10d

CLAIM CODES (Designated by NUCC)

S

Required when submitting a bill that is a duplicate or an appeal. (Original Refernece Number must be entered in Box 22 for these conditions).

Enter the NUBC Condition Code Qualifier 'BG' followed by the appropriate NUBC Condition Code for resubmission.

W2 - Duplicate of the original bill

W3 - Level 1 Appeal (Request for Second Review)

W4 - Level 2 Appeal

W5 - Level 3 Appeal

Example: BGW3

Note: Do note use condition codes when submitting revised or corrected bill.

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

California Workers' Compensation Instructions

11

ISURED'S POLICY GROUP OR FECA NUMBER

O

For workers' compensation, the "insured' is the employer. The provider may enter the employer's workers' compensation insurance policy number.

11a

INSURED'S DATE OF BIRTH, SEX

N

11b

OTHER CLAIM ID (Designated by NUCC)

S

Required if known. Enter qualifier Y4 to left of vertical line and enter workers' compensation claim number assigned by the claims administrator to the right of the vertical like. If claim number is not known then enter the value of 'Unknown' to indicate unknown claim number. This box requires one of the above values and cannot be left blank or may result in the bill being rejected.

11c

INSURANCE PLAN NAME OR PROGRAM NAME

S

Required when the Employer Department Name/Division is applicable and is different than Box 4.

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

S

Required if applicable.

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

O

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

N

14

DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)

R

For Specific Injury: Enter the date of incident or exposure.

For Cumulative Injury or Occupational Disease: Enter date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment. (Calif. Labor Code §5412.)

15

OTHER DATE

S

Required if applicable. Enter applicable qualifier and date.

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

O

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE

S

Required when Referring Provider, Ordering Provider or Supervising Provider providers is associated with the bill. Enter applicable qualifier and provider name.

17a

OTHER ID #

S

Required when other providers are associated with the bill and do not have an NPI# Enter '0B' qualifier followed by the State License Number of the provider.

17b

NPI #

S

If known.

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

S

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

S

Box 19 is also to be used to communicate the Attachment Information, if applicable. Attachment Information is required in Box 19 and on supporting document(s) associated with this bill, when the document (s) is submitted separately from the bill.

Refer to California Workers’ Compensation Companion Guide regarding Attachment Information data requirements. Enter the three digit ID qualifier PWK, the appropriate two digits Report Type Code, e.g. Radiology Report Code = RR, the appropriate two digit Transmission Type Code, e.g. FAX =FX, followed by the unique Attachment Control identification number. Do not enter spaces between qualifiers and data. Example: PWKRRFX1234567.

When the documentation represents a Jurisdictional Report, then use the Report Type Code ‘OZ’, and enter the Jurisdictional Report Type Code in front of the Attachment Control Number. Example: PWKOZFXJ1999234567

Summary: Enter the first qualifier and number/code/information in Box 19. After the first item, enter three blank spaces and then the next qualifier and number/code/information.

20

OUTSIDE LAB?

S

Use when billing for diagnostic tests (refer to CMS instructions).

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

California Workers' Compensation Instructions

21.A

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

R

21.B

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.C

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.D

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.E

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.F

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.G

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.H

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.I

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.J

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.K

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

21.L

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

22

RESUBMISSION CODE

S

Required when the bill is a resubmission. Enter the Original Reference Number assigned to the bill by the Claims Administrator.

When the Original Reference Number is entered and a Condition Code is not present in 10d the Bill is considered a Revised Bill for reconsideration.

When resubmitting a bill as a revision or a reconsideration, enter the appropriate NUBC Bill Frequency Codes left justified in the left-hand side of the field. Both codes are needed. There is no frequency code for a duplicate bill. The values will be: 7 – Replacement of prior claim (bill) 8 – Void/cancel of prior claim (bill) The Resubmission Code is not intended for use for original bill submissions.

23

PRIOR AUTHORIZATION NUMBER

S

Required if a prior authorization, referral, concurrent review, or voluntary certification number was received. Enter the number/name as assigned by the payer for the current service. Do not enter hyphens or spaces within the number.

24A

DATE(S) OF SERVICE

R

24B

PLACE OF SERVICE

R

24C

EMG

N

24D

PROCEDURES, SERVICES, OR SUPPLIES

R

24E

DIAGNOSIS CODE POINTER

R

24F

$ CHARGES

R

24G

DAYS OR UNITS

R

24H

EPSDT/FAMILY PLAN

N

24I Grey

ID QUAL

S

Required when the Rendering Provider is a health care provider. Enter 'ZZ' Qualifier for Taxonomy Code of the Rendering Provider.

24J Grey

RENDERING PROVIDER ID. #

S

Required when the Rendering Provider is a health care provider. Enter the Taxonomy Code of the Rendering Provider.

24J

NPI#

S

Required when the Rendering Provider is different from the provider reported in Box 33 and the provider is eligible for an NPI.

24 Grey

GREY AREA SUPPLEMENTAL DATA

S

Required when supplemental data is being submitted.

25

FEDERAL TAX ID. NUMBER

R

26

PATIENT'S ACCOUNT NO.

R

27

ACCEPT ASSIGNMENT?

N

28

TOTAL CHARGE

R

29

AMOUNT PAID

N

30

RSVD FOR NUCC USE

N

31

SIGNATURE OF PHYSICIAN OR SUPPLIER

O

32

SERVICE FACILITY LOCATION INFORMATION

R

32a

NPI #

S

Required if entity populated in Box 32 is a licensed health care provider eligible for an NPI #. Enter the NPI # of the service facility location in field 32A

32b

OTHER ID #

S

Enter state license number if service facility location is not eligible for an NPI.

33

BILLING PROVIDER INFO & PH #

R

Required as provided in 1500 Health Insurance Claim Form Reference Manual, however, if an assignee is to be the payee, identify here.

33a

NPI #

S

33b

OTHER ID #

S