The CMS 1500 claim form can sometimes cause confusion and difficulty for providers trying to understand it. This form is a critical component of the billing process for providers looking to receive reimbursement for their services. Most therapists are probably familiar with how tedious and picky payers can be when it comes to the accuracy of the claims and forms you submit to them. Every detail needs to be filled out perfectly or they will find cause to deny your reimbursement. Denied claims are a waste of time for therapists who just want to focus on their clients, not the hassles of billing. So what is the 1500 claim form, when should therapists use it, and how can you simplify the process to maximize your reimbursements? Keep reading to find out.
What is the 1500-Claim Form and When is it Used?
The 1500 form was created and is maintained by the National Uniform Claim Committee (NUCC) and is referred to most commonly as CMS-1500. According to CMS, this form can be used by non-institutional providers to bill Medicare carriers. It is also used for billing select Medicaid State Agencies.
This form was originally created for providers to submit claims for reimbursement to government insurance payers. Today, it is a standard form used by private payers as well. The digital equivalent of this form is 837 EDI. This form is to be used anytime it is required by a payer to submit a claim manually or digitally.
Formatting Requirements When Filling Out the Form
The NUCC is in charge of setting the requirements for both HIPAA 837 and CMS-1500. Providers that work with payers know just how many requirements there are to adhere to in order to get paid. Those requirements include:
- Your EHR/EMR should give you access to this form but can also be found in other places online. Most payers follow the formatting set by the NUCC. The form must be printed in color, using the standard font (no bold/italic/special characters), and readable (no stuffing too much information into single lines).
- If printing and mailing the form, it must be printed in color, free of flaws, and readable.
- If filling out the forms manually, it must be done in black ink, be readable, in all capital letters, and only use the lines available to write down information.
1500 Claim Form Instructions for Therapists
When it comes down to the information you put into the CMS-1500 claim form, the sheet can be broken down into sections. Those sections are as follows:
Every detail in the section must be accurate or the claim will get denied.
- Check off the patient’s insurance, or the type of insurance you plan to submit the claim to.
- The patient’s name (Last, First, and Middle Initial)
- Patient DOB
- Insured’s name (This name might be different than the patient’s name if they are on a family member’s plan)
- Patient address
- Patient relationship to insured
- Insured’s address
- Leave this section blank. It is not for you to fill out.
- Secondary insurance: Insured’s Name
- Other insurance group ID
- Leave this blank
- Leave this blank
- Insurance plan name
- Is the patient’s condition related to one of these items?
- Their employment? Check yes or no
- An auto accident? Check yes or no
- Another type of accident? Check yes or no
- Insured’s policy group or FECA Number – this must be filled out if you checked yes to 10a/b/c
- Insured’s DOB & sex
- Claim identifiers designated by the NUCC. (Y4 = submitting the form to property and casualty payers) and the corresponding claim ID.
- Insurance plan name
- Is there another health benefit plan? Check yes or no. If yes, fill out 9 and 9a/d
- Patient’s or authorized person’s signature. Enter “signature on file” or “SOF” when appropriate. If using a legal signature, also fill out the date.
- Insured’s authorized person’s signature. Repeat steps from 12.
Condition and Treatment Information
- Onset date (MM DD YYYY) of the current condition. Modifier 431 for the onset of current symptoms or illness. Or Modifier 484 for pregnant patient’s last menstrual cycle.
- Any other applicable dates that are related to the client’s current condition and treatment. List qualifying modifiers here as well.
- Date of client’s inability to work if applicable
- Referring provider
- Referring provider’s state license number or commercial number. 0B modifier on the left for state, and G2 Modifier for commercial. Also, list their 10 digit NPI number.
- Fill out if “a direct result of, or subsequent to, a related hospitalization” when applicable along with the date of that hospitalization.
- This section varies from payer to payer
- Were lab services rendered? Check yes or no. Include dollar amount, no commas, decimal points, or dollar signs.
- Diagnosis code. In the right corner, include the number 0 to show that you are using ICD-10 codes. In sections, A-L use the ICD-10 codes that represent the “sign, symptom, complaint, or condition” as they relate to the services you delivered.
- This section is only for resubmissions. 7 for the replacement of a previous claim or 8 to cancel or void a prior claim. Include the original reference number.
- Payer authorization number
- Services delivered to the client. This is an important section and must be accurate.
- Start and end dates of service.
- Place of service code
- Was this an emergency? Check yes or no
- Enter CPT code for billing along with modifiers.
- Diagnosis code references letters
- The dollar amount being billed with code
- Number of units being billed
- This section varies by the payer. Was this covered under a state plan? Respond accordingly.
- The type of provider identification number you are using and the corresponding modifier
- The number that corresponds to the modifier in the previous section along with your NPI
- Employer ID or SSN of the billing provider
- Client account number
- Do you accept assignments under the payer’s terms? Check yes or no
- Total dollar amount being charged
- Payments already received from the client
- Leave this blank
- Provider’s legal signature with credentials or SOF and date
- a//b/c name, address, city, state, and nine-digit zip code where services were rendered.
- a/b/c name, address, city, state, and nine-digit zip code of the billing provider