A CMS 1500 form is filled in by healthcare providers when they need to file a Medicare claim. Once it has been filled in completely, it will be sent to Medicare carriers, as well as Medicare Administrative contractors and the contractors who are in charge of the Medical Equipment.
Below are some steps to follow when completing a CMS 1500 form.
• Enter the type of claim in the first Box.
• In Box 1a, write down the patient's ID number that will be stated on their Benefits ID card.
• In Box 2, you should write down the patient's last name, then their first name and the first initial of their middle name. (Do not use commas).
• Enter their date of birth in the following format - MM/DD/YYYY.
• Tick the correct gender box.
• Write the patient's mailing address and telephone number in the fifth box.
• In Box 8, tick the appropriate boxes for the patient's marital status and employment status.
• If the patient also happens to be covered by another insurance policy, then list the name in Box 4.
• If this claim is the only one being made then leave boxes 4, 6 and 7 completely blank. But if you have filled in box 4 then you should also fill in 6 and 7.
• Box 9 will probably be left blank as this is only used if Medigap coverage applies.
• State in box 10 whether the claim is due to an injury or accident.
• Boxes 12 and 13 are for signatures.
• In box 14, write down the date of the accident or the date that the illness started.
• Box 15 is not used.
• If the patient is not working then fill in box 16.
• Box 17 should be entered to contain the name of the patient's healthcare provider.
• Box 17a is not used.
• In box 17b, write the patient's National Provider Identifier number.
These are the parts of the form that usually cause patients and family the most trouble. It is very easy to complete the form from now on as instructions are clearly stated. However, if you ever have any difficulties filling in the boxes then you should get in touch with whoever issued the form to you.
Below are some steps to follow when completing a CMS 1500 form.
• Enter the type of claim in the first Box.
• In Box 1a, write down the patient's ID number that will be stated on their Benefits ID card.
• In Box 2, you should write down the patient's last name, then their first name and the first initial of their middle name. (Do not use commas).
• Enter their date of birth in the following format - MM/DD/YYYY.
• Tick the correct gender box.
• Write the patient's mailing address and telephone number in the fifth box.
• In Box 8, tick the appropriate boxes for the patient's marital status and employment status.
• If the patient also happens to be covered by another insurance policy, then list the name in Box 4.
• If this claim is the only one being made then leave boxes 4, 6 and 7 completely blank. But if you have filled in box 4 then you should also fill in 6 and 7.
• Box 9 will probably be left blank as this is only used if Medigap coverage applies.
• State in box 10 whether the claim is due to an injury or accident.
• Boxes 12 and 13 are for signatures.
• In box 14, write down the date of the accident or the date that the illness started.
• Box 15 is not used.
• If the patient is not working then fill in box 16.
• Box 17 should be entered to contain the name of the patient's healthcare provider.
• Box 17a is not used.
• In box 17b, write the patient's National Provider Identifier number.
These are the parts of the form that usually cause patients and family the most trouble. It is very easy to complete the form from now on as instructions are clearly stated. However, if you ever have any difficulties filling in the boxes then you should get in touch with whoever issued the form to you.
