4.3 CMS-1500 Form Complete Field-by-Field Rules

4.3 CMS-1500 Form Complete Field-by-Field Rules

1. Introduction to the CMS-1500 (02/12) Professional Claim Form

The CMS-1500 claim form (current version 02/12, approved by the Office of Management and Budget under OMB No. 0938-1197) is the standard paper claim form prescribed by the Centers for Medicare & Medicaid Services (CMS) and maintained by the National Uniform Claim Committee (NUCC). It is utilized by individual physicians, mid-level practitioners (such as Physician Assistants and Nurse Practitioners), physical therapists, independent laboratories, durable medical equipment (DME) suppliers, and other non-institutional healthcare providers to bill professional services to Medicare, Medicaid, TRICARE, Workers' Compensation, and commercial health plans.

Paper CMS-1500 forms are printed in specialized OCR drop-out red ink (specifically Pantone 245 or special red formulation) to facilitate Optical Character Recognition (OCR) scanner parsing. When completing paper claims, medical billers must adhere to strict formatting standards: capital letters only, no punctuation (such as hyphens in social security numbers or periods in diagnosis codes), standard 8-digit date formats (MM DD YYYY), and precise alignment within box borders to avoid OCR scanning rejections.

---

2. Patient and Insured Information (Boxes 1–13)

Boxes 1 through 13 on the top half of the form collect demographic data, primary and secondary insurance policy information, legal authorizations, and liability indicators essential for coordination of benefits (COB).

Box 1: Health Insurance Coverage Type

Check the appropriate checkbox corresponding to the primary payer type:

• MEDICARE: Federal Medicare Part B or Medicare Advantage.
• MEDICAID: State fee-for-service Medicaid or Medicaid Managed Care.
• TRICARE: Department of Defense active duty or retiree military health program.
• CHAMPVA: Department of Veterans Affairs dependents health coverage.
• GROUP HEALTH PLAN: Employer-sponsored commercial insurance or private group coverage.
• FECA BLK LUNG: Federal Employees' Compensation Act or Black Lung benefits.
• OTHER: Commercial individual plans, auto liability, or self-insured commercial plans.

Box 1a: Insured's ID Number

Enter the primary policyholder's unique insurance identification number as shown on the member card (e.g., Medicare Beneficiary Identifier [MBI], subscriber ID, or policy number). Hyphens and spaces must be omitted.

Box 2: Patient's Name

Enter the patient's legal name formatted as LAST NAME, FIRST NAME, MIDDLE INITIAL or separated by spaces without commas if required by scanner software.

Box 3: Patient's Birth Date & Sex

Enter the patient's 8-digit date of birth (MM DD YYYY) and check the appropriate box (M for Male, F for Female).

Box 4: Insured's Name

Enter the full name of the primary policyholder (LAST NAME, FIRST NAME, MIDDLE INITIAL). If the patient is the primary insured, enter SAME (or re-enter the patient's name based on payer guidelines).

Box 5: Patient's Address

Enter the patient's permanent residential address, including street address, city, 2-letter state abbreviation, and 5-digit or 9-digit ZIP code.

Box 6: Patient Relationship to Insured

Check the box establishing the patient's relationship to the primary policyholder: Self, Spouse, Child, or Other.

Box 7: Insured's Address

Enter the primary policyholder's address. If identical to Box 5, enter SAME.

Box 8: Reserved for NUCC Use

This field was previously used for patient marital and employment status but is currently reserved for future NUCC standards. Leave blank.

Box 9 & 9a–d: Other Insured's Name & Secondary Coverage

Completed ONLY when secondary or supplemental insurance coverage exists (e.g., Medigap, secondary commercial plan, or spouse's insurance plan):

• Box 9: Enter the secondary insured's full name.
• Box 9a: Enter the secondary policy or group number (for Medigap, enter MEDIGAP or the Medigap plan ID).
• Box 9b: Reserved for NUCC use.
• Box 9c: Reserved for NUCC use.
• Box 9d: Enter the secondary insurance plan name or program name.

Box 10a–c: Is Patient's Condition Related To:

Mandatory indicators that establish primary payer liability and third-party liability rules:

• 10a: Employment (Current or Previous): Check YES if the encounter resulted from a workplace injury or occupational disease (routes claim to Workers' Compensation). Check NO otherwise.
• 10b: Auto Accident: Check YES if the condition resulted from a motor vehicle accident, and enter the 2-letter state postal abbreviation where the accident occurred. Routes primary liability to auto medical payment coverage.
• 10c: Other Accident: Check YES if the condition resulted from a non-auto personal injury or premises liability accident.

Box 11 & 11a–d: Insured's Group & Primary Plan Details

This box serves as the gateway for primary plan adjudication:

• Box 11: Enter the primary insured's group number, policy number, or FECA claim number. If no group number exists, enter NONE.
• Box 11a: Enter the insured's 8-digit birth date (MM DD YYYY) and sex.
• Box 11b: Enter Other Claim ID designated by NUCC (such as Property and Casualty Claim Number).
• Box 11c: Enter the complete primary Insurance Plan Name or Program Name.
• Box 11d: Is There Another Health Benefit Plan?: Check YES or NO. If YES is checked, Box 9, 9a, and 9d MUST be completed to allow coordination of benefits.

Box 12: Patient's or Authorized Person's Signature

Authorizes the release of medical records necessary to process the claim. Entering SIGNATURE ON FILE or SOF with the date signifies that a signed authorization is retained in the patient's record.

Box 13: Insured's or Authorized Person's Signature

Authorizes the Assignment of Benefits (AOB), directing the insurance payer to issue payment directly to the healthcare provider. Entering SIGNATURE ON FILE or SOF indicates valid authorization on file.

---

3. Clinical, Diagnostic, and Service Information (Boxes 14–33)

Boxes 14 through 33 capture clinical diagnostic codes, procedural service lines, provider identifiers, and billing entity details.

Box 14: Date of Current Illness, Injury, or Pregnancy

Enter the 8-digit date (MM DD YYYY) of the onset of current illness, injury, or Last Menstrual Period (LMP) for obstetric care. Include a 3-digit qualifier in the shaded top portion (e.g., qualifier 431 for Onset of Current Symptoms/Illness, 484 for Last Menstrual Period).

Box 15: Other Date

Enter relevant secondary clinical dates using appropriate qualifiers (e.g., qualifier 454 for Initial Treatment Date, 435 for Initial Date of Current Illness).

Box 16: Dates Patient Unable to Work in Current Occupation

Enter the FROM and TO dates (MM DD YYYY) if the patient is disabled from work due to the current condition (essential for disability and Workers' Compensation claims).

Box 17, 17a, & 17b: Referring / Ordering Provider Information

Report the referring or ordering physician's name and NPI:

• Box 17: Enter the provider's full name preceded by the appropriate qualifier: DN (Referring Provider), DK (Ordering Provider), or DQ (Supervising Provider).
• Box 17a: Shaded field for legacy provider identification numbers (PIN) preceded by qualifier (e.g., G2 for Commercial PIN, 1B for Blue Shield).
• Box 17b: Enter the provider's 10-digit National Provider Identifier (NPI).

Box 18: Hospitalization Dates Related to Current Services

Enter the FROM and TO admission and discharge dates if the professional services were rendered during an inpatient hospital stay.

Box 19: Additional Claim Information

Used for unlisted CPT code narrative descriptions, NOC (Not Otherwise Classified) drug details (NDC numbers, dosage, strength), shared/split visit indicators, or specific payer narrative requirements.

Box 20: Outside Lab & Charges

Check YES if diagnostic laboratory tests were performed by an independent laboratory outside the billing physician's office, and enter the total lab charges. Check NO if performed in-house.

Box 21: Diagnosis or Nature of Illness or Injury

Enter up to 12 ICD-10-CM diagnosis codes establishing medical necessity for services rendered:

• ICD Indicator: Enter code 0 in the small box at the top right to signify ICD-10-CM diagnosis codes (code 9 was used for legacy ICD-9).
• Rows A through L: Enter valid ICD-10-CM codes in fields labeled A through L. Do NOT include decimals (e.g., enter E119 or E11.9 depending on payer OCR guidelines, though decimals are standard in electronic format).

Box 22: Resubmission Code & Original Reference Number

Used for submitting corrected, replacement, or voided claims:

• Resubmission Code: Enter 7 for Replacement/Corrected Claim, or 8 for Void/Cancel Claim.
• Original Ref. No.: Enter the original payer claim control number (ICN/DCN) assigned to the initial claim.

Box 23: Prior Authorization Number

Enter the pre-certification, prior authorization, Quality Improvement Organization (QIO) approval, or referral number issued by the payer.

Box 24A–J: Line Item Service Details

Contains six individual service lines (rows 1–6). Each line features a shaded top half (for supplemental details like NDC numbers or taxonomy) and an unshaded bottom half:

• 24A: Dates of Service: Enter FROM and TO dates (MM DD YY or MM DD YYYY) for each specific procedure.
• 24B: Place of Service (POS): Enter the 2-digit HIPAA Place of Service code (e.g., 11 Office, 21 Inpatient Hospital, 22 Outpatient Hospital, 12 Home, 31 Skilled Nursing Facility, 81 Independent Lab).
• 24C: EMG: Enter Y for Emergency services, otherwise leave blank.
• 24D: Procedures, Services, or Supplies: Enter the 5-digit CPT or HCPCS Level II code and up to four 2-character modifiers (e.g., CPT 99214 with modifier -25).
• 24E: Diagnosis Pointer: Enter alpha pointers (A through L) corresponding to the diagnosis codes in Box 21 that justify the medical necessity of this specific line item. Up to 4 pointers can be listed per line (e.g., A, B). Do NOT enter actual ICD-10 code numbers here.
• 24F: $ Charges: Enter the total dollar charge for the specific line item (e.g., 175 00).
• 24G: Days or Units: Enter the number of services or units billed (e.g., 1 for office visit, 2 for lab test).
• 24H: EPSDT / Family Planning: Enter state-specific Medicaid Early and Periodic Screening, Diagnostic, and Treatment indicators (Y or N).
• 24I: ID Qualifier: Enter ZZ in the shaded area if reporting a Provider Taxonomy Code in 24J.
• 24J: Rendering Provider ID: Enter the rendering provider's 10-digit NPI in the unshaded bottom area. Enter non-NPI legacy ID in the shaded top area.

Box 25: Federal Tax ID Number

Enter the billing provider or facility's 9-digit Federal Tax Identification Number (Employer Identification Number [EIN] or Social Security Number [SSN]) and check the corresponding EIN or SSN box.

Box 26: Patient's Account No.

Enter the internal patient accounting number assigned by the medical practice to link payments in the billing system.

Box 27: Accept Assignment?

Check YES or NO. Checking YES indicates the provider agrees to accept the payer's allowed fee schedule as payment in full and will not balance bill the patient for amounts exceeding the contracted rate (except copays/deductibles).

Box 28: Total Charge

Enter the sum of all charges listed in Box 24F (lines 1 through 6).

Box 29: Amount Paid

Enter any advance payments made by the patient (such as copayments paid at the time of service) or primary insurance payments prior to secondary billing.

Box 30: Reserved for NUCC Use

Previously labeled Balance Due; currently reserved for NUCC guidelines. Leave blank.

Box 31: Signature of Physician or Supplier

Signature of the practitioner or authorized representative, including professional degrees/credentials (e.g., MD, DO, NP), and the date signed. SIGNATURE ON FILE is acceptable.

Box 32, 32a, & 32b: Service Facility Location Information

Enter the physical facility name, street address, city, state, and ZIP code where services were actually rendered:

• 32a: Enter the 10-digit NPI of the service facility location.
• 32b: Enter the 2-digit qualifier and legacy facility identifier.

Box 33, 33a, & 33b: Billing Provider Info & Ph

Enter the billing practitioner or organization name, street address, city, state, ZIP code, and telephone number:

• 33a: Enter the 10-digit NPI of the Billing Provider.
• 33b: Enter qualifier ZZ followed by the 10-character Provider Taxonomy Code, or legacy billing group number.

---

4. Critical Form Locators Quick Reference Table