In California, healthcare providers use the CMS-1500 (HCFA) Form to file original workers' compensation medical bills.
Article Contents |
Navigation Link |
CMS-1500 (HCFA) |
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Reporting Requirements |
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Timely Filing |
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Filling out the Form |
CMS-1500 (HCFA) Services
The following table provides a link to the California rules which require a provider to use the CMS-1500 (HCFA) for billing purposes.
Service |
Rule |
Physician Services |
|
DMEPOS | |
Laboratory / Pathology | |
Ambulance Services |
CMS-1500 Required Billing Documentation
For a complete bill, California requires the provider to submit the following supporting documentation with the CMS-1500 Form, when applicable.
CMS-1500 Medical Bill |
Required Supporting Documentation |
PTP First Visit |
A Doctor’s First Report of Occupational Injury (Form 5021), must be submitted when the bill includes Evaluation and Management services and a Doctor’s First Report of Occupational Injury is required under Title 8, California Code of Regulations § 9785. |
PTP Progress Report |
A PR-2 report or its narrative equivalent must be submitted when the bill is for Evaluation and Management services and a PR-2 report is required under Title 8, California Code of Regulations § 9785. |
PTP P&S Report |
A PR-3, PR-4 or their narrative equivalent must be submitted when the bill is for Evaluation and Management services and the injured worker’s condition has been declared permanent and stationary with permanent disability or a need for future medical care. (Use of Modifier –17) |
Consultation |
A narrative report must be submitted when the bill is for Evaluation and Management services for a consultation. |
Laboratory / Radiology / Diagnostic Testing |
A descriptive report must be submitted when the Official Medical Fee Schedule indicates that a report is required. |
By Report |
A descriptive report of the procedure, drug, DME or other item must be submitted when the provider uses any code that is payable “By Report”. |
Unlisted DME or Physician Dispensed drugs |
An invoice or other proof of documented paid costs must be provided when required by statute or by the OMFS for reimbursement. |
Modifiers -22, -23, -25 |
A report must be submitted when the provider uses the following Modifiers –22, –23, and –25. |
Surgery |
An operative report is required when the bill is for either professional or facility Surgery Services fees. |
Previously Requested Additional Information |
Appropriate additional information reasonably requested by the claims administrator or its agent to support a billed code when the request was made prior to submission of the billing. |
Authorization |
Any evidence of authorization for the services that may have been received. |
Prescriptions |
The prescription or referral from the primary treating physician if the services were performed by a person other than the primary treating physician, except as set forth in (A) and (B). (A) A copy of the prescription is not required with a request for payment for pharmacy services, unless the provider of services has entered into a written agreement that requires a copy of a prescription for a pharmacy service. (B) An employer, insurer, pharmacy benefits manager, or third-party claims administrator may request a copy of the prescription during a review of any records of prescription drugs that were dispensed by a pharmacy. (C) Any entity that has submitted a pharmacy bill for payment on or after January 1, 2013, and denied payment for not including a copy of the prescription from the treating physician, may resubmit those bills for payment until March 31, 2014. |
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Timely Filing
Billing forms must be filed within 12 months of the date of service for all services rendered in California.
Form |
Timely Filing |
California Labor Code |
Rule |
Billing Forms |
12 Months |
Division 4, Chapter 2, Article 2. Medical and Hospital Treatment. |
For additional information related to reporting please refer to DaisyBill’s California Billing Guide.
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CMS-1500 Form Instructions
Whether you’re filing your CMS-1500 electronically or on paper, Daisybill is here to help keep you compliant. This video is DaisyBill’s step-by-step guide to filing a paper CMS-1500.
Video Summary
Uniform billing requirements for health providers make the CMS-1500 Form central to medical billing for healthcare professionals. In Coding a CMS-1500 Form, DaisyBill walks through the form comprehensively; showing you how to file compliant paper CMS-1500 forms and answering the many questions that arise along the way.
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CMS-1500 Crosswalk Table
The state of California requires providers to compliantly complete the CMS-1500 Form as detailed in the following tables.
For additional information, review the complete NUCC Manual:
1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12
Items 0 through 10
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 |
|
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. |
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Items 11 through 20
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). |
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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 |
21 |
ICD IND. |
||
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 |
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