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
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.
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.
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)
line below (24E)
22 Not Required Resubmission Code - It is used to send
corrected claim with
appropriate frequency code and claim number
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 OR 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.
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
Where do we enter refferal number
ReplyDeleteIn box# 23 and thanks for your response, we have updated the above post.
DeleteHello Team,
ReplyDeletePlease post some interview questions for physician & Hospital billing to gain some more information other than denial most of the interviewers will ask small details.
Sure, we will create a post on interview questions.
Deleteinterview preparations questions u haven't posted so many are still waiting
DeleteHello! I am billing Anesthesia and BCBS reps are saying that Service facility NPI in box 32 needs to be enrolled with the tax id of the billing provider in box 25..this is the first time I am hearing something like this, could anyone validate?
ReplyDeleteThis is a credentialing denial. You can go through the below post to get some idea about the credentialing process.
Deletehttps://www.arlearningonline.com/2022/04/credentialing-process.html
In addition to that, you need to understand that a claim is always getting billed under billing provider information. You can find the billing provider's name and address in Box# 33, NPI in Box # 33a & Tax ID in Box # 25 on the CMS1500 form.
So, all the entities who are working for billing providers such as rendering providers, referring providers, and service facilities need to be enrolled with billing providers. If they are not enrolled then will get the credentialing denial.
Hi could you Please change 24G as DAYS or UNITS , It is listed as DAYS OF UNITS
ReplyDeleteThank you for pointing this out. It has been corrected.
DeleteHello Team,
ReplyDeletePlease post some interview questions for AR Denial/ physician/Hospital billing to gain some more information other than denial most of the interviewers will ask small details.
preparation for hospital billing interview questions pls?
ReplyDeleteHow to prepare interview small details questions other than denial in a dedicated post separation
ReplyDeleteif I am working in a hospital billing ub04 and did for 2 years if I give next interview are there any hiring chances for me to be selected in Physician billing as CMS1500? or I cannot join?
ReplyDeleteYour chances will be dependent on the knowledge that you have gained from your experience and if you showed that you have an ability to learn quickly then there should not be any issue.
DeleteYou will only not get consider if the organization looks for a candidate who has experience in physician billing.