How to Fill Out CMS 1500

Form CMS-1500 is a U.S. health insurance claim form used to file claims made by a doctor or hospital service provider. All medical locations must fill out the form if they wish to be reimbursed for their services and supplies by the U.S. Medicare program. Learn how to fill out the form accurately, as some of the form entry boxes may seem confusing or ambiguous to individuals completing it for the first time.

Difficulty: Moderately Easy

Instructions

1. Fill out the first block on the form, which describes the patient involved in the insurance claim. Copy the applicable information from the patient's personal data submitted when she received treatment. You need information such as the patient's birth date and full name. Note the health insurance coverage box, in which you enter the patient's Medicare Health Insurance number from her Medicare card on file.

2. Cross-reference the fourth box, regarding the patient's insurance, with the information he submitted when admitted. Some patients have private insurance in addition to Medicare if their spouse or partner has such coverage. If the patient is covered by another individual, enter her name into this area of the CMS-1500. If both the insured individual and the patient are identical, write "SAME."

3. Skip section nine on the CMS-1500 unless the patient has expressed interest in assigning his Medigap benefits to your medical establishment. If the patient requested the assigning of his Medigap benefits, fill out the appropriate lines in section nine that request data such as the patient's Medigap number.

4. Check the boxes in section 10, which indicate whether the specific incident connected to the medical claim is connected to an external liability, such as an automobile accident. Select either the "Yes" check box or the "No" check box.

5. Fill out section 11. This field is mandatory and governs whether the patient's medical establishment has attempted to determine if the case is covered by Medicare. If the patient has other insurance, enter the applicable insurance information here (for example, the Blue Cross plan number).

6. Complete the remaining sections, entering the specific contact information for the patient's medical establishment. Include the physician involved in the case, as well as the establishment's phone number and mailing address.

7. Enter the patient treatment information, referring back to the bill of services provided by the medical establishment. This includes length of stay by the patient, as well as cost of treatment and supplies. Tally the total and enter it at the bottom of the form.

8. Have the patient sign and date the form. File according to the practices of the patient's hospital or medical establishment. The medical establishment will submit the form in accordance to its general operation schedule.

Tips & Warnings

• You can order a blank CMS-1500 form from the U.S. Government Printing Office by calling [phone].
• An incomplete form cannot be processed and will be sent back to the medical service provider, adding considerable delays to the total time it takes to process and receive reimbursement.

References

• Medicaire Claims Processing Manual
• CMS-1500 Provider Training Manual

Resources

• About the CMS-1500 Form and Related Services

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