CMS-1500 Claim Instructions
Review a box-by-box description for the CMS-1500 claim form.
Tired of figuring out your CMS-1500 boxes?
Below is a complete, step-by-step breakdown of the CMS-1500 form, also known as the HCFA 1500 form, with a short title and long description for each box.
The CMS-1500 form is a recognizable form, printed on a red template, and is the standard form used by providers to bill Medicare, Medicaid, and private insurers for outpatient services.
Patient & Insured Information
| Box # | Short Description | Long Description |
|---|---|---|
Box 1 | Insurance Type | This indicates the type of health insurance plan and policy (Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, or Other). The information in this box directs how the claim will be processed. |
Box 1a | Insured ID Number | Enter the patient’s policy number, group, or identification number as assigned by the payer. Policy numbers can also sometimes be called Subscriber ID or Member ID. |
Box 2 | Patient Name | The full legal name of the patient (last, first, middle initial). This must match the name the payer has on file, so ensure that you do not enter a preferred name here. |
Box 3 | Patient Birthdate and Sex | Enter the patient’s date of birth (in format MM/DD/YYYY) and the gender of the patient that is on record with the insurance company. |
Box 4 | Insured Name | Enter the name of the policyholder, if it is different from the patient. |
Box 5 | Patient Address | Enter the full mailing address, including city, state, and ZIP code for the patient. |
Box 6 | Patient Relationship to Insured | This indicates whether the patient is the insured (self), spouse, child, or other relative of the insured. |
Box 7 | Insured Address | Complete this box if the address of the insured is different from the patient’s address. |
Box 8 | Reserved for NUCC Use | This box is not used and should be left blank. |
Box 9 | Other Insured Name | Enter the name of another policyholder if a secondary insurance exists for the insured. The boxes in series 9 can be left blank if not applicable. |
Box 9a | Other Insured’s Policy/Group Number | If you entered Box 9, add the policy or group number of the secondary insurance. |
Box 9b | Reserved for NUCC Use | This box is not used and should be left blank. |
Box 9c | Reserved for NUCC Use | This box is not used and should be left blank. |
Box 9d | Insurance Plan Name or Program Name | Enter the name of secondary insurance plan, if boxes 9 and 9a were completed. |
Box 10a | Patient’s Condition Related To | Box 10 helps specify the claim type further, asking whether the services are related to employment, auto accident, or other accident. Check “NO” if not applicable. |
Box 10b | Patient’s Condition Related To | Box 10 helps specify the claim type further, asking whether the services are related to employment, auto accident, or other accident. Check “NO” if not applicable. If the service is related to an auto accident, also include the two-letter state abbreviation. |
Box 10c | Patient’s Condition Related To | Box 10 helps specify the claim type further, asking whether the services are related to employment, auto accident, or other accident. Check “NO” if not applicable. |
Box 10d | Claim Codes (Designated by NUCC) | This is used for claim identifiers (such as property or casualty case numbers, clinical trial identifiers, or most commonly, workers’ compensation case numbers). This box should be left blank if it is not applicable. |
Box 11 | Insured’s Policy Group/FECA Number | Enter the Primary insured’s group or policy number. If the primary policy is Medicare, leave this box blank, otherwise complete this box (which is duplicative of Box 1a). |
Box 11a | Insured’s Birth Date & Sex | Enter the patient’s date of birth (in format MM/DD/YYYY) and the gender of the patient that is on record with the insurance company. |
Box 11b | Employer’s Name or School Name | Employer or school of insured. |
Box 11c | Insurance Plan Name or Program Name | Enter the name of primary insurance plan. |
Box 11d | Is There Another Health Benefit Plan? | Indicate if the patient has an additional (secondary) insurance policy. |
Box 12 | Patient’s/Authorized Person’s Signature | Signature authorizing release of medical information. This box is usually (with electronic claims in particular) completed with “Signature on File” of “SoF” with the date the signature was obtained for your internal records. |
Box 13 | Insured’s/Authorized Person’s Signature | Signature authorizing payment of benefits to provider. This box is usually (with electronic claims in particular) completed with “Signature on File” of “SoF” with the date the signature was obtained for your internal records. |
Provider & Service Information
| Box # | Short Description | Long Description |
|---|---|---|
Box 14 | Date of Current Illness/Injury/Pregnancy (LMP) | Date symptoms began, accident occurred, or last menstrual period. |
Box 15 | Other Date | Specify another relevant date (e.g., first consultation, accident date). Leave blank if not applicable. |
Box 16 | Dates Patient Unable to Work | Enter the date range that the patient was unable to work due to condition, if applicable. Otherwise, leave blank. |
Box 17 | Name of Referring Provider | Enter the name of the referring physician or other source. |
Box 17a | Other ID Number | Legacy provider identifiers if required (e.g. UPIN or state license number). This is generally blank. |
Box 17b | NPI | Add the NPI (National Provider Identifier) of the referring provider, if applicable. |
Box 18 | Hospitalization Dates Related to Current Services | Enter the Admission and Discharge dates, if related to this claim. |
Box 19 | Additional Claim Information | Extra notes to payer (e.g., unlisted codes, modifiers). This is usually blank. |
Box 20 | Outside Lab? Charges? | Indicates if an outside lab was used and the charges. If labs were completed in house, mark NO. |
Box 21 | Diagnosis or Nature of Illness/Injury | ICD-10 (or ICD-9 legacy) diagnosis codes for the encounter. These may vary from other diagnoses the patient has on record. |
Box 22 | Resubmission Code/Original Ref. Number | Enter reference numbers when resubmitting a claim (or for a corrected claim). |
Box 23 | Prior Authorization Number | Enter the authorization or referral number assigned by payer, if applicable. Otherwise, leave blank. |
Procedures & Charges
| Box # | Short Description | Long Description |
|---|---|---|
Box 24a | Date(s) of Service | Enter the Start and End dates of service. In many cases, the start and end dates will be the same. |
Box 24b | Place of Service | Enter the two-digit code for service location (office, hospital, telehealth, etc.). |
Box 24c | EMG (Emergency Indicator) | Use this field to indicate if services were an emergency. This is generally left blank. |
Box 24d | Procedures, Services, or Supplies (CPT/HCPCS & Modifiers) | Enter the CPT/HCPCS codes here that describe the services provided (e.g. 90837 or 99204, etc.). |
Box 24e | Diagnosis Pointer | Your entry here is linked to the diagnosis code entered in Box 21. Do not enter the diagnosis code, but the alpha-numeric identifier from Box 21. |
Box 24f | Charges | Enter your billed charge for each service line to the payer. |
Box 24g | Days or Units | Enter the number of services, time units, or dosage. |
Box 24h | EPSDT/Family Plan | Indicates Early & Periodic Screening, Diagnosis, Treatment (EPSDT) or family planning. This is often left blank. |
Box 24i | ID Qualifier | Legacy qualifier for Box 24j. This is generally left blank or filled with “ZZ”, to indicate that you are submitting an NPI in Box 24j. |
Box 24j | Rendering Provider ID (NPI) | Enter the 10-digit NPI of the individual rendering provider. |
Totals & Billing Provider
| Box # | Short Description | Long Description |
|---|---|---|
Box 25 | Federal Tax ID Number | Enter the provider’s EIN or SSN used for tax and billing. |
Box 26 | Patient’s Account Number | Enter your patient control number or patient ID number for your own internal tracking and charting. |
Box 27 | Accept Assignment? | Indicates if provider accepts payer’s allowed amount as payment in full. This should generally be checked YES. |
Box 28 | Total Charge | This should be the total sum of all charges from the service lines entered in the Box 24 series. |
Box 29 | Amount Paid | Denote any prior payment by patient or other insurer. |
Box 30 | Reserved for NUCC Use | This box is not used and should be left blank. |
Box 31 | Signature of Physician or Supplier | Add the provider’s signature, or mark “Signature on File or “SOF”, which is most common in electronic claim submission. |
Box 32 | Service Facility Location Information | Enter the address where services were rendered if not the provider’s office, and include the full nine-digit zipcode to avoid a denial or rejection. |
Box 32a | Service Facility NPI | Enter the 10-digit NPI of the facility. |
Box 32b | Other ID (Legacy) | Secondary ID if required by payer. This is usually blank. |
Box 33 | Billing Provider Info & Phone Number | Enter the provider’s billing name, address, and phone number. |
Box 33a | Billing Provider NPI | Enter the 10-digit NPI of the billing provider. |
Box 33b | Other ID (Legacy) | This field is used for any other legacy billing IDs, but is generally left blank. |
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