Claim forms, such as the CMS-1500, serve as the backbone of the revenue cycle management (RCM) for healthcare practices. It serves key functions that expand beyond requesting payment for the rendered care services.
When you submit the claim form, you initiate the payment collection process. Besides, it acts as a legal document between the provider, payer, and the patient. That’s not all! It links the performed procedure to the patient’s condition, justifying the medical necessity.
Thus, in this guide, we will discuss everything you need to know about filling the CMS-1500 claim form and how to prevent the common mistakes. So, continue reading!
What is a CMS-1500 Claim Form?
It is a standardized claim form that non-institutional providers use to submit details related to patient demographics, diagnosis, treatments, and provider information for timely payment processing.
The CMS-1500 form can be used by physical therapists, chiropractors, physicians, surgeons, and practitioners at outpatient clinics.
Before we discuss the technicalities of filling this form, it is essential that you understand what the 837P form is.
Undoubtedly, the CMS-1500 claim form is foundational, but it is a paper-based form. The future indeed is digital. That’s where 837P comes into play. It is the electronic version of CMS-1500 and mirrors all its fields.
How to Fill Out a CMS-1500 Form?
This section will provide a comprehensive walkthrough on how to fill out the non-institutional claim form accurately:
Block 1-13 (Patient and Insured Information)
The table below explains how to accurately fill in the 1-13 block fields of the CMS-1500 claim form:
| Block # | Field Name | How to Fill It? |
|---|---|---|
| 1 | Insurance Type | Check the box that applies. Use ‘Others’ for most commercial plans. |
| 1a | Insured’s ID Number | State the ID number exactly as it appears on the insurance card. |
| 2 | Patient’s Name | Fill the patient’s full legal name (last name, first name, middle initial). |
| 3 | Patient’s Birth Date, Sex | Enter the patient’s date of birth (MM/DD/YYYY) and mark the corresponding gender box. |
| 4 | Insured’s Name | If the patient is the insured subscriber, leave this blank (or enter the same as the one you entered in block 2). However, if the patient is a dependent, write the subscriber’s full legal name. |
| 5 | Patient’s Address | Mention the patient’s current street address, city, state, and zip code. |
| 6 | Patient’s Relation to Insured | Select the appropriate box. |
| 7 | Insured’s Address | If it is different from the one you mentioned in block 5, enter the insured’s address. Otherwise, leave this blank. Also, leave this blank if block 4 was left blank. |
| 8 | Reserved for National Uniform Claim Committee (NUCC) Use | – |
| 9 | Other Insured’s Name | If secondary insurance exists, include the secondary insured’s name. |
| 10 | Is Patient’s Condition Related To: | Mark the box that is most relevant. (Required for injury claims only). |
| 11 | Insured’s Policy Group or FECA Number | State the group number for the primary insurance policy. |
| 12 | Patient’s or Authorized Person’s Signature, Date | Indicate Signature on File (SOF) if an assignment of benefits form has been signed. |
| 13 | Insured’s or Authorized Person’s Signature | Indicate SOF if the authorization to release information has been signed. |
Box 14-33 (Provider/Supplier Information)
This section of the CMS-1500 claim form is for details related to the performed services, the dates, the diagnoses, and the billing provider’s information:
| Block # | Field Name | How to Fill It? |
|---|---|---|
| 14 | Date of Current Illness, Injury, or Pregnancy | Mention the first date the patient experienced symptoms, was injured, or the last menstrual period (LMP) for maternity claims. |
| 15 | Other Date | – |
| 16 | Dates Patient Unable to Work in Current Occupation | Enter the date the patient first became unable to perform their job due to the illness or injury (mandatory for Workers’ Compensation). |
| 17 | Name of Referring Provider or Other Source | State the name and National Provider Identifier (NPI) of the referring/ordering physician. |
| 18 | Hospitalization Dates Related to Current Services | If the patient was hospitalized, fill in the dates of hospitalization. |
| 19 | Additional Claim Information | – |
| 20 | Outside Lab | Check ‘Yes’ if the services were provided by an outside lab or if DME was provided. |
| 21 | Diagnosis or Nature of Illness or Injury | List the primary diagnoses using the appropriate ICD-10 codes (up to 12). |
| 22 | Resubmission Code | Fill the original claim reference number (if applicable) |
| 23 | Prior Authorization Number | Mention the specific authorization number (if applicable). |
| 24 | Rendered Service/Procedure Details | Include details related to each rendered service, including date, place, procedure code, diagnosis code, charges, and more. |
| 25 | Federal Tax ID Number | Enter the group’s TIN or EIN. Also, check the specific box to indicate whether it is a social security number (SSN) or an employer ID number (EIN). |
| 26 | Patient’s Account No | State the patient’s account number assigned by the provider’s billing system. This helps with tracking and posting payments. |
| 27 | Accept Assignment | Check ‘Yes’ if you agree to accept the payer’s allowed amount as payment in fullSelect ‘No’ to bill the patient for the difference. Note: Medicare/Medicaid providers must always check ‘Yes’. |
| 28 | Total Charge | Sum of all charges from block 24. |
| 29 | Amount Paid | Amount already paid (if any). |
| 30 | Reserved for NUCC Use | – |
| 31 | Signature of Physician or Supplier | The billing provider must sign and date the form. |
| 32 | Service Facility Location Information | Mention the location where services were provided. |
| 33 | Billing Provider Info & Phone Number | Include the billing provider’s official name, address, phone number, and the NPI. |
Mistakes in Filling CMS-1500 Form
Discussed below are some of the common mistakes that non-institutional providers make when billing for services using the CMS-1500 claim form:
1. Errors in Patient Information
An incorrect insurance ID or a missing date of birth may seem like minor mistakes. However, they are enough to halt claim processing.
The reason? Insurance payers often leverage automated systems to double-check all required fields on the CMS-1500 form. Thus, if the patient’s details do not match their record, they do not reimburse for the billed services.
Pro Tip: Always double-check the patient’s demographic information at the time of check-in to prevent payment delays.
2. Wrong ICD-10, CPT Code Pair
What happens when the diagnosis code does not match the procedural code? The payer denies reimbursement due to a lack of medical necessity.
Pro Tip: Ensure that block 24E, which requires you to add diagnostic pointers accurately, aligns with the billed service. Besides, you can use automation tools to verify that the ICD-10 code aligns with the specific CPT code before submitting the CMS-1500 claim form.
3. Incorrect or Missing NPI
NPI numbers help in the correct identification of healthcare providers. Thus, entering wrong details or leaving the block fields 24J blank may lead to instant claim denial.
Pro Tip: Proactively maintain an NPI directly and regularly audit claim templates to prevent this error in the future.
4. Inappropriate or Missing Modifiers
Modifiers may seem like small add-ons, but they offer clarity to the payer on how a specific service was performed. As a result, using the wrong modifiers or skipping them altogether can impact the reimbursement payment and amount.
Pro Tip: Try to be as specific as possible when submitting the CMS-1500 formwith the help of modifiers. But be wary! Because overusing or misusing modifiers may lead to audit risks.
5. Skipping Resubmission Details
Block field 22 decides whether you will receive payment for a resubmitted claim. How? Because it asks you to write the original claim’s reference number to indicate that it is a resubmission. Thus, if you forget to fill in this field of the CMS-1500 form, it will result in claim duplication.
Pro Tip: When dealing with a claim resubmission, train your staff to check the field no. 22.
6. Missing Prior Authorization Number
Many payers require you to obtain pre-authorization for specific services (typically expensive procedures). It is a way to seek approval from the payer before rendering the procedure to ensure it will be reimbursed.
Thus, it will result in payment rejection if you miss adding details to block field 23 for a procedure requiring payer approval.
Pro Tip: Cross-check whether the billed procedure required prior authorization. If yes, make sure to submit the CMS-1500 formwith a pre-auth number.
7. Incomplete Service Facility or Provider Details
When things do not add up in fields 32 and 33, like where you rendered the service, payment delays can occur.
Pro Tip: Validate that all details related to the practice’s location and the billing provider, such as name, address, and NPI, are accurate.
CMS-1500 vs UB-04: Understanding the Difference
The following tables offer an at-a-glance view of CMS-1500 vs. UB-04 claim form:
| CMS-1500 Claim Form | UB-04 Claim Form | |
|---|---|---|
| Used When | Billing for professional services, such as the physician’s time and skill. | Billing for institutional/facility services, i.e., the cost of the equipment, room, resources, etc. |
| Who Bills? | Non-facility providers (physicians, surgeons, therapists, etc.). | Facility providers (hospitals, SNFs, surgery centers, hospice, etc.). |
| Key Service Code | CPT codes | Revenue codes |
| Example | The surgeon’s fee for performing the procedure. | The hospital’s charges for the operating room and supplies. |
Conclusion
Hopefully, this detailed guide will help you streamline your billing workflow, leading to faster payments and a seamless revenue cycle.
We discussed not only how to fill the CMS-1500 claim form accurately, but also how to avoid common mistakes when filling the form. Moreover, we offered a brief overview of how this form differs from UB-04.
However, if you are still having trouble managing denied claims, we recommend outsourcing denial management services to professionals, like MediBillMD.
