Medical Billing Cycle - Healthcare

CMS 1500 blocks instructions in Medical Billing

CMS 1500 Form:

CMS 1500 Form also known as HCFA 1500 and has 33 blocks. This form is used by providers to submit a claim to the insurance company for the reimbursement of the health care services rendered to patients.

CMS 1500 BlocksDescriptionInstructions to fill outRequired/Optional Block
CMS 1500 Block 1There are seven varieties of health insurance plan to select from.Select one amongst the seven varities of health insurance plant by ticking(X) suitable Block from the list.Optional Block (If applicable)
CMS 1500 Block 1aInsured's Insurance Identification NumberEnter the Insured's ID number, which is displayed on the insurance ID card for the insurance to which the claim is being billed.Required Block
CMS 1500 Block 2Name of the PatientEnter the name of the Patient (Last name, fore name and middle initial).Required Block
CMS 1500 Block 3Patient's Birth Date and Sex (Male/Female)Enter the Patient's Birth date in MM/DD/YYYY format and indicate the gender (Male/Female) of the Patient by ticking the Block.Required Block
CMS 1500 Block 4Insured's NameThis Block is optional only if Insured and patient are same. If the patient name is different from Insured's name, then we would like to enter insured's name.Optional Block (If applicable)
CMS 1500 Block 5Patient's Address together with Telephone NumberEnter the patient full and permanent address and telphone numberRequired Block
CMS 1500 Block 6Patient's Relationship to Insured ( we would like to select one from the subsequent options: Self/Spouse/Child/Other)Tick mark whichever applicable to patientOptional Block (If applicable)
CMS 1500 Block 7Insured's Address together with the Telephone NumberEnter Policy holder address and telephone numberOptional Block (If applicable)
CMS 1500 Block 8Reserved for National Uniform Claim Committee use
CMS 1500 Block 9 (a to d)9 : Another insurance policy name for this patient, which covers the health care services of the patient - Other Insured's Name

9a : Another policy or group number which covers the health care services of the patient - Other Insured's policy or group number

9d: Another insurance Plan name or programme name which covers this health care services of patient.
Block 9, 9a and 9d must be entered, when CMS 1500 Block 11d is completed.Optional Block (If applicable)
CMS 1500 Block 10a to 10cEmployement (Current or previous)/Auto Accident/Other AccidentTick mark appropriate optionOptional Block (If applicable)
CMS 1500 Block 10dReserved for NUCC useLeave Blank
CMS 1500 Block 11 (a to d)11 Insured Policy Group or FECA Number

11a Insured DOB and Sex

11b Other Claim ID(Designated by NUCC)

11c Insurance plan or programme name

11d is there another health benefit plan ( If yes complete CMS 1500 Block 9, 9a and 9d)
If CMS 1500 Block 4 is completed:
Then enter insured policy/group number, DOB, Sex(Male/Female), employer/school name and Insurance plan/programme name as displayed on the member insurance ID card.
Optional Block (If applicable)
CMS 1500 Block 12Patients or Authorized person's signature.Enter "Signature on file".

It indicates that patient or gurantors as signed a form to release medical information for entities who are all involved in medical billing cycle.
Required Block
CMS 1500 Block 13Insured's or Authorized person's signatureThis CMS 1500 Block 13 should have a phrase "Signature on file".

This is to point to the payer to pay the reimbursement of health care claims on to the provider.
Required Block
CMS 1500 Block 14Date of Current illness, injury or pregnancyEnter the date of injury or illness occurred onset date and if it’s a pregnancy, then enter LMP (Last Menstrual period).Required Block
CMS 1500 Block 15Other DateIf the previous date for the identical patient had same or similar illness, then key those dates during entering this Block.Optional Block (If applicable)
CMS 1500 Block 16Dates Patient unable to work in current occupation (From and To date)Enter the span of dates (from and to) when patient is employed and unable to figure in their current occupationOptional Block (If applicable)
CMS 1500 Block 17 (a to b)17 Name of the referring provider or other service. Enter one of the Qualifiers:

DN(Referring provider), DK(Ordering provider) and DQ(Supervising provider))

17a Referring provider identification number.

17b Referring provider NPI number
If the service is referred by a referring physician then enter this CMS 1500 Block 17 (a to B)

Note: 17a leave empty, because it isn't reported.
Optional Block (If applicable)
CMS 1500 Block 18Hospitalization span dates associated with current health care services (From and To)Enter the admission and discharge dates, if patient identifies an inpatient stay.Optional Block (If applicable)
CMS 1500 Block 19Additional Claim informationReserved for Local Use, when procedures require additional informationOptional Block (If applicable)
CMS 1500 Block 20Outside Lab (yes or no)Select appropriate by ticking(X) the suitable Block.

If "yes", then it indicates the entity performed the diagnostic assay is other then the entity billing this service.

If "no", then it indicates no purchased diagnostic tests are included on the claim.
Required Block when biling the diagnostic tests
CMS 1500 Block 21Diagnosis or Nature of illness or injuryEnter the diagnosis code as per ICD 10 CODERequired Block
CMS 1500 Block 22Resubmission CodeLeave Blank
CMS 1500 Block 23Prior Authorization NumberEnter the prior authorization number for the services which require prior approval.Required Block (If applicable)
CMS 1500 Block 24aDates of service (From and to)Enter the dates when the patient was treatedRequired Block
CMS 1500 Block 24bPlace of ServiceEnter the place of service codes from the lists, to point where the health care services rendered.Required Block
CMS 1500 Block 24cEMG (Emergency Indicator)Leave Blank
CMS 1500 Block 24dProcedures, services or supplies (CPT/HCPCS and Modifiers)Enter appropriate modifiers, procedures or supplies using HCPCS code when applicableRequired Block (If applicable)
CMS 1500 Block 24eDiagnosis pointerEnter the dianosis code letter(A to L) from CMS 1500 Block 21 that applies to the procedure code indicated.Required Block
CMS 1500 Block 24f$ ChargesEnter the prices of each line in dollar amount.Required Block
CMS 1500 Block 24gDays/units (It is a measures of medical services, such as the number of hospital days, pints of blood, kidney dialisis treatments, etc.)Note: Don't leave blank, because the units should be atleast entered as 1.Required Block
CMS 1500 Block 24hEPSDT/Family planLeave Blank
CMS 1500 Block 24iID QualifierLeave Blank
CMS 1500 Block 24jRendering Provider ID#Enter the treating provider NPI numberRequired Block
CMS 1500 Block 25Federal Tax ID number (SSN and EIN)Enter the Federal Tax ID number assigned by the federal to doctors and hospitals for tax purposes. (Format is 3-2-4)Required Block
CMS 1500 Block 26Patient Account NumberPatient Account number also called as encounter number. Enter the encounter number given by doctor or hospital for each and every patient's medical visit.Required Block
CMS 1500 Block 27Accept Assignment (Yes or No)Check the block with X.
If its "yes" then provider agrees to simply accept the assignment of payers benefit.
Required Block
CMS 1500 Block 28Total ChargeEnter overall charges of the servicesRequired Block
CMS 1500 Block 29Amount paidEnter overall amount paid by patient and/or other insurances for this service.Required Block
CMS 1500 Block 30Reserved for NUCC useLeave Blank
CMS 1500 Block 31Signature of Physician or Supplier including degrees or credentialsEnter the signaute of physician or Supplier (Note: Stamped signatures are accepted)Required Block
CMS 1500 Block 32Service Facility location informationEnter name, address of the place where the health care services delivered.Required Block
CMS 1500 Block 32aNational Provider Identifier (NPI)Enter the NPI number of the facilityRequired Block
CMS 1500 Block 32bID Qualifier and PINLeave Blank (eff 05/23/2008 it's to not be reported)
CMS 1500 Block 33Billing provider information and phone numberEnter name, address and number of the billing providerRequired Block
CMS 1500 Block 33aNPI of the billing providerEnter the NPI number of the billing providerRequired Block
CMS 1500 Block 33bID Qualifier and PINLeave Blank (eff 05/23/2008 it's to not be reported)