What Is Required on a Cms-1500 Form

The Health and Safety Plan Processing System is designed to process standard health insurance application forms (CMS 1500) using CPT-4 process codes or the Common Healthcare Procedures Coding System (HCPCS) with appropriate modifiers and ICD-10 CM diagnostic codes. Medicare electronic claims transactions must meet the requirements of electronic data exchange. Medicare RDN providers can file claims with applications that meet Medicare EDI requirements. Suppliers must enter into an EDI registration agreement. Professional diet nutritionists can submit applications electronically to a Medicare Administrative Contractor (MAC). Dietitians should contact their MACs for more information. To access the application form template, click on the following link: CMS 1500 Sample Security Health Plan Claim Form considers an application to be completed when the following data elements are submitted (numbered as shown on the application form). Fields printed in italics are only mandatory in applicable situations. 1. Type of health insurance cover applicable to this claim – see Box 1a for this claim. Identification number 2 of the insured. Patient name 3. Date of birth/sex of patient 4.

Insured name (“Equal” or left blank is not acceptable.) 5. Patient address 6. Patient`s relationship with the insured 7. Address of the insured (street, city, state, postal code) 8. Not required 9. Name of other insured – If item number 11d is enabled, fill in 9, 9a and 9d, otherwise leave the 10 field blank. Check the appropriate box if the patient`s condition is related to: 10a. Use 10b. Car accident (field 15 required) 10c. Other accident (field 15 required) 10d.

Not required 11th insurance group of the insured or FECA number 11a. Date of birth of the insured (MM/DD/YY) and sex 11b. Not required 11c. Name of the insurance plan or name of the 11d program. Enter an “x” in the correct field 12. Signature of the patient or authorized person (“Signature in the record” is acceptable) 13. Signature of the insured or authorized person 14. Date of illness, injury, pregnancy (PMT) 15. Alternate date – Enter the appropriate qualifier and accident date if field 10b or 10c is enabled 16.

Not required 17. Name of referring provider or other source (field 17b required) 17a. Not required 17b. NPI of the referring supplier of 17 18. Hospitalization appointments related to current services 19. Additional information on claims 20. Outside the lab – enter an “x” in the correct field and, if so, enter the purchase price 21. Diagnosis or type of illness or injury (ICD-10-CM) 22. New submission code and/or original reference number 23.

Pre-approval number 24a. Red shaded area: N4 qualifier, followed by 11-digit NDC code, quantity qualifier and quantity. 24a. White area: Delivery date(s) (MM/DD/YY) 24b. Place of work 24c. EMG: Emergency notification 24d. Procedure, services or consumables (CPT/HCPCS & modifier) 24th. Diagnostic pointer 24f. Charging quantity 24g. Days or units 24h. Not required 24i.

Qualifier that identifies the vendor ID in the corresponding 24d field: Required for BadgerCare claims if an NPI and rendering provider taxonomy are reported in 24d 24d. NPI Rendering Provider (blank) – Required if the rendering provider is different from the billing provider. Note: Physiotherapy, occupational therapy and speech-language pathology requests billed on a CMS 1500 form must include the National Rendering Provider ID (NPI). The NPI of the rendering provider and, if applicable, the taxonomy must be entered in box 24J of cms 1500. This ensures correct processing and payment of services. 24j: Rendering provider taxonomy (shaded in red) – Required for BadgerCare claims: Enter the taxonomy that corresponds to the render provider`s NPI entered in field 24j (white area). 25. Federal Tax Identification Number (TIN) and check the appropriate box 26. Patient account number – identified and assigned by the provider 27. Accept assignment – Select the appropriate check box if the vendor accepts assignment 28.

Total Fees – Sum of all fees in 24f29. Amount paid – Payment from another payer or patient (no discount) 30. Not required 31. Signature of physician or provider, including diplomas or references 32. Location of service establishment – Name and address of the establishment where the services were provided 32a. Location of the NPI service establishment – NPI for the location of the service establishment in 32 (report only one NPI for the location of the service facility if the NPI is different from the billing provider`s NPI) 32b. Not required 33. Information and telephone number of the billing provider – name, address and telephone number of the supplier requesting payment for the services provided 33a. NPI of the billing provider – NPI of the billing provider indicated in box 33 33b. Billing Provider Taxonomy – Required for BadgerCare Claims: Enter the appropriate qualifier and taxonomy that corresponds to the billing provider`s NPI entered in field 33a The CMS-1500 application form is used to send non-institutional requests for health services from physicians, other providers, and providers to Medicare. It is also used to file claims with many private payers and Medicaid programs, as well as other government health insurance programs.

Most requests for institutional services are submitted via a Form UB-04. Supplier contracts and billing policies provide additional instructions for settling claims. If you want to study outsourcing claims and billing, consider the factors to consider when choosing a professional billing service. .