CMS-1500 Claim Form Completed Sample, Uses and Instructions

The Center of Medicaid and Medicare Services (CMS) form 1500 is used to bill SFHP for medical services. The form is used by Physicians and Allied Health Professionals to submit claims for medical services.

The CMS-1500 is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and 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 National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form.

CMS-1500 Claim Form Uses

The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers, and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs. Provider agreements and billing guidelines provide additional instruction for claims completion. If you want to explore outsourcing claims and billing see factors to consider when selecting a professional billing service.

CMS-1500 Claim Form Instructions

The CMS-1500 claim form instructions are:

Provider Types

The instructions for the CMS-1500 claim form are to help the following categories of provider types:

Physicians
Physician Assistants
Ambulance
Ambulatory Surgical Centers
Certified Registered Nurse Anesthetists
Community Mental Health
Durable Medical Equipment (DME)
Federally Qualified Health Centers
Hearing Aid Providers
Independent Laboratory
Independent Radiology
Chiropractic Care
Podiatrists
Mental Health Services
Nurse Practitioners
Optical/ Vision Providers
Perinatal High-Risk Management
Pharmacy Disease Management
Private Duty Nursing
Rural Health Clinics
Therapy Services
Waiver Services

Paper Claim Reminders

Information should be completed accurately to ensure proper claim adjudication.

Complete an original CMS-1500 claim form.
No photocopied claims will be accepted.
Use blue or black ink.
Do not use highlighters.
Do not use correction fluid or correction tape.
Be sure the information on the form is legible.
make sure that names, codes, numbers, etc. print in the chosen fields for proper alignment.
The claim must be signed.
No multiple-page claims may be submitted.
The six service lines in Locator 24 have been divided horizontally to accommodate the submission
of supplemental information along with NPI and other identifiers such as taxonomy codes or
legacy identifiers. The top shaded portion of each service line is for reporting supplemental
information. It is not intended to allow the billing of twelve service lines. Each
procedure, service, drug, or supply must be listed on its own claim line in the bottom, un –
the shaded portion of the claim line.

Paper Claims with Attachments

Follow the below-given guideline when submitting attachments with the CMS-1500 claim form:

The attachment should be marked with the beneficiary’s name and Medicaid ID number.
A copy of the attachment must accompany each claim for different claims that refer to the same attachment.
For claims with more than one third-party payor source, include all EOBs that relate to the
claim.
For third-party payments less than 20% of charges, indicate on the face of the claim, Less then 20%, proof attached.
For Medicare denials, indicate on the claim, Medicare denial, see attached.
For other insurance denials, indicate on the claim, TPL denial, See attached.

Electronic CMS-1500 Claims

Electronic CMS-1500 claims may be submitted to Mississippi Medicaid by these methods:

Electronic CMS-1500 claims must be submitted in a format that is HIPAA compliant with the ANSI X12CMS-1500 claim standards. When completing claims electronically select a payer ID, a unique code for each payer. Some payers may require providers to complete an agreement before they will accept electronic claims through a third-party service.

Medicare electronic claims transactions must meet Electronic Data Interchange requirements. Providers must complete an EDI enrollment agreement. Registered dietitian nutritionists are able to submit claims electronically to a Medicare Administrative Contractor (MAC). Registered dietitian nutritionists should contact their MACs for more information.

Be sure to include prior authorization number, timely filing TCN, proper procedure codes,
modifiers, units, etc., to prevent your claim from denying inappropriately.