CMS 1500 FORM

There are two types of claim forms for payment reimbursement: 

1. CMS 1500 - CMS 1500 claim form is a medical claim form used by individual doctors & practices, nurses, and professionals including therapists, chiropractors, and outpatient clinics. It contains 33 boxes.

2. UB 04 - UB 04 claim form also known as CMS 1450 is used by hospitals, nursing facilities, and inpatient and other facility providers. It contains 81 Locators. 

Below are the details of each box of CMS 1500:

Box#    Requirement     Description

  1           Optional           Insurance Type

  1a         Required          Insured's ID Number

  2           Required          Patient's Name (Last Name, First Name, Middle Initial)

  3           Required          Patient's Birth Date & Sex

  4         If Applicable       Insured's Name (Last Name, First Name, Middle Initial)

  5           Required          Patient's Address & Telephone

  6         If Applicable       Patient Relationship to Insured

  7        Not Required       Insured's Address & Telephone

  8        Not Required       Reserved for NUCC Use - Unused Field

  9        Not Required       Other Insured's Name (Last Name, First Name, Middle Initial)

 9a       Not Required       Other Insured's Policy OR Group Number

 9b       Not Required       Reserved for NUCC Use - Unused Field

 9c       Not Required       Reserved for NUCC Use - Unused Field

 9d       Not Required       Insurance Plan OR Program Name

 10       Not Required       Is Patient's Condition Related To:

                                a. Employment? (Current or Previous)

                                b. Auto Accident?

                                c. Other Accident?

10d      Not Required       Claim Codes (Designated by NUCC) - It is used to identify additional
                                     information about the patient's condition or the claim. When required
                                     by payer, enter the condition code in the field.

 11       Not Required       Insured's Policy Group OR FECA Number

11a      Not Required       Insured's Date of Birth & Sex

11b      Not Required       Claim ID (Designated by NUCC) - This box is entered with workers
                                     compensation claim number.

11c       If Applicable       Insurance Plan Name OR Program Name

11d        Required           Is There Another Health Benefit Plan?

 12       Not Required       Signature & Date

 13       Not Required       Insured's or Authorized Person's Signature

 14         Required           Date of Current Illness, Injury or Pregnancy (LMP)

 15       Not Required       Other Date

 16       Not Required       Dates Patient Unable to Work in Current Occupation

 17       If Applicable        Name of Referring Provider

17a      If Applicable        ID Number of Referring Provider

17b.     If Applicable        Referring Physician NPI#

 18       If Applicable        Hospitalization Dates Related to Current Services

 19       If Applicable        Additional Claim Information (Designated by NUCC)

 20       If Applicable        Outside Lab? With $ amount

 21         Required           Diagnosis Code OR Nature of Illness OR Injury Relate A-L to service
                                     line below (24E)

 22       Not Required       Resubmission Code - It is used to send corrected claim with
                                     appropriate frequency code and claim number

 23       If Applicable        Prior Authorization Number / Referral Number

24a         Required          Date(s) of Service

24b         Required          Place of Service

24c         Required          Emergency Indicator It is used to indicate emergency services.

24d         Required          Procedures, Services, OR Supplies - CPT & Modifier

24e         Required          Diagnosis Pointer

24f          Required          Charge Amount

24g         Required          Days of Units

24h      If Applicable        EPSDT Family Plan - It is used to indicate family planning services.

24i       If Applicable        ID Qualifier - It is used to indicate qualifier for the ID listed in box 24j.

24j       If Applicable        Rendering Provider ID#/NPI

 25          Required          Federal Tax ID Number

 26          Optional           Patient's Account No.

 27       Not Required       Accept Assignment? - It is used to indicate that the provider agrees to
                                     accept assignment under the terms of the payer's program.

 28          Required          Total Charge

 29       If Applicable        Amount Paid

 30       If Applicable        Reserved for NUCC Use - Unused Field

 31          Required          Signature of Physician and Date

 32          Required          Service Facility Location Information

32a         Required          Service Facility Location's NPI

32b      If Applicable        Service Facility Location's Provider ID

 33          Required          Billing Provider Information & Phone#

33a         Required          Billing Provider NPI#

33b         Required          Billing Provider ID/Taxonomy

Click here for the details of UB 04