CMS 1500 Billing Guide

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S
S

NR
NR

S
S

R
NR

KEY

REQUIRED

SITUATIONAL --- ONLY IF APPROPRIATE TO THIS CLAIM

NOT REQUIRED/NOT USED

18.

HOSPITAL DATES RELATED TO CURRENT SERVICES S
Enter the hospital dates using an eight-digit date format (MM/DD/CCYY).

19.

ADDITIONAL CLAIM INFORMATION (DESIGNATED BY NUCC)

20.

OUTSIDE LAB/CHARGES R
Select “Yes” or “No” to indicate if the claim includes charges for lab services performed outside
of the physician’s office. If “Yes,” enter the total charges.

21.

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY R
Enter the ICD-9-CM codes. The primary diagnosis should be entered first, followed by other
diagnoses if applicable. Up to three additional ICD-9-CM codes can be entered.

22.

RESUBMISSION

23.

PRIOR AUTHORIZATION NUMBER

24.

SHADED AREA – SUPPLEMENTAL INFORMATION –
The shaded area of field 24a - 24h was created to accommodate supplemental information, i.e., Anesthesia.
For more information, see the National Uniform Claim Committee’s website at www.nucc.org.

24A.

DATE(S) OF SERVICE R
Enter the dates of service using an eight-digit date format (MM/DD/CCYY).

24B.

PLACE OF SERVICE R
Enter the appropriate two-digit Place of Service code.

24C.

EMG S
If this service was an emergency, enter “Y” for “Yes,” or leave blank if “No”.

24D.

PROCEDURES, SERVICES, OR SUPPLIES R
Enter the CPT or HCPCS code for the procedures, services or supplies, and enter a modifier if applicable.

24E.

DIAGNOSIS POINTER R
Enter the appropriate ICD-9-CM diagnosis code or codes for each procedure performed. Enter one
code per line of service.

24F.

CHARGES R
Enter the charge for each line of service. Do not include discounts.

24G.

DAYS OR UNITS R
Enter the number of days or units for each line of service.

24H.

EPSDT/FAMILY PLAN S
If applicable, enter the appropriate Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
code or family planning (FP) code.

TYPE OF HEALTH INSURANCE COVERAGE
Select “Other”

1A.

INSURED ID NUMBER R
Enter the subscriber’s identification number

PATIENT’S NAME R Last name, First name, Middle initial
Enter the patient’s last name, first name and middle initial.

PATIENT’S BIRTH DATE/SEX R
Enter the patient’s date of birth using the eight-digit date format (MM/DD/CCYY).
Next, select the patient’s gender.

Last name, First name, Middle initial
INSURED’S NAME
Enter the insured’s last name, first name and middle initial.

PATIENT’S ADDRESS/TELEPHONE NUMBER R
Enter the patient’s permanent mailing address and telephone number.

PATIENT’S RELATIONSHIP TO THE INSURED R
Select the appropriate box for patient’s relationship to the insured person.

INSURED’S ADDRESS/TELEPHONE NUMBER S
Enter the insured person’s permanent mailing address (complete if different from the patient’s address)

RESERVED FOR NUCC USE

OTHER INSURED’S NAME S
Enter the other insured person’s last name, first name and middle initial. When the patient has other
insurance coverage, you will need to complete fields 9a through 9d. This information is necessary to
coordinate benefits with other insurance companies.

9A.

OTHER INSURED’S POLICY OR GROUP NUMBER S
Enter the other insured person’s policy or group number.

9B.

RESERVED FOR NUCC USE NR
Enter the other insured person’s date of birth in an eight-digit date format (MM/DD/CCYY).

9C.

RESERVED FOR NUCC USE NR
Enter the other insured person’s employer or school name.

9D.

INSURANCE PLAN NAME OR PROGRAM NAME S
Enter the name of the other insured person’s insurance plan or program name.

24I.

ID QUALIFIER - SHADED FIELD NR
Not required, reserved for taxonomy code qualifier, “ZZ.”

10A-D.

IS PATIENT’S CONDITION RELATED TO:
For 10a – 10d, required status is contingent upon a definitive “Yes” or “No” answer. If you are unsure,
leave blank.

24J.

RENDERING PROVIDER ID. #
SHADED FIELD NR
Not required, reserved for taxonomy code.

10A.

Select whether the patient’s condition is related to employment.

10B.

Select whether the patient’s condition is related to an auto accident and enter the state in which the
accident occurred. Use two-character abbreviation, i.e. IL. S

10C.

Select whether the patient’s condition is related to any other type of accident.

10D.

CLAIM CODES (DESIGNATED BY NUCC)

11.

INSURED’S POLICY GROUP OR FECA NUMBER
Enter the subscriber’s ID number again.

11A.

INSURED’S DATE OF BIRTH, SEX R
Enter the subscriber’s date of birth using the eight-digit date format (MM/DD/CCYY) and
select the subscriber’s gender.

OTHER CLAIM ID (DESIGNATED BY NUCC)
Enter the subscriber’s employer or school name.

11C.

INSURANCE PLAN NAME OR PROGRAM NAME R
Enter the subscriber’s insurance plan name (PCU or RMA or UC)

11D.

12.

PATIENT OR AUTHORIZED PERSON’S SIGNATURE

13.

INSURED OR AUTHORIZED PERSON’S SIGNATURE

14.

DATE OF CURRENT ILLNESS, INJURY, OR PREGNANCY (LMP)
Enter the date using an eight-digit date format (MM/DD/CCYY).

15.

OTHER DATE S
Enter the date using an eight-digit date format (MM/DD/CCYY).

16.

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
Enter the date using an eight-digit date format (MM/DD/CCYY).

17.

FEDERAL TAX ID NUMBER R
Enter the Federal Tax ID Number for the provider of service. Select the appropriate field for SSN or EIN.

26.

PATIENT ACCOUNT NUMBER S
Enter account number assigned to the patient, if applicable.

27.

ACCEPT ASSIGNMENT R
Select “Yes” if the provider should be paid, or select “No” if the patient should be paid.

28.

TOTAL CHARGE R
Enter the total charge for all services (total of all charges in 24f).

29.

AMOUNT PAID S
Enter any amount paid by the patient only. Do not enter any amount by Medicare or other insurance.

30.

RSVD FOR NUCC USE NR
Enter the difference, if any, between the total charge and the amount paid.

31.

SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDE DEGREES OR CREDENTIALS R
The claim must be signed by the physician/supplier or an authorized representative. The form must also
be dated, using an eight-digit date format (MM/DD/CCYY).

32.

SERVICE FACILITY LOCATION INFORMATION S
Enter the location where the services were rendered. The provider of service must identify the
supplier’s information when billing for purchased diagnostic tests.

IS THERE ANOTHER HEALTH INSURANCE BENEFIT PLAN
Select whether there is another health insurance plan. Remember, if there is another health
insurance plan, you will need to complete fields 9, 9a, and 9d. This information is necessary to
coordinate benefits with other insurance companies.

25.

11B.

NON-SHADED FIELD R
Enter the performing provider’s 10-digit NPI number in the non-shaded area.

Note: Per the NUCC Instruction Manual, Field 32 is required if Field 20 is checked “yes.”
For more information, see the National Uniform Claim Committee’s website at www.nucc.org.
32A.

NPI S
Enter the 10-digit NPI number of the service facility location.

32B.

OTHER ID# NR
Not required, reserved for taxonomy code (preceded by “ZZ” qualifier).

33.

BILLING PROVIDER INFO AND PH# R
Enter the information of the billing provider or supplier to be paid for services.

33A.

NPI R
Enter the 10-digit NPI number of the billing provider.

33B.

OTHER ID # NR
Not required, reserved for taxonomy code (preceded by “ZZ” qualifier).

NAME OF REFERRING PROVIDER OR OTHER SOURCE
Enter the referring, ordering or supervising provider’s first name, middle initial, last name and
credentials. This field is required only if there is a referring, ordering or supervising provider.

17A.

OTHER ID# NR
Not required, reserved for taxonomy code (preceded by “ZZ” qualifier).

17B.

NPI # S
Enter the 10-digit NPI number of the referring, ordering or supervising provider.

Place of Service Codes
CODES
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27-30
31
32
33
34
35-40
41
42
43-48
49
50
51
52
53
54
55
56
57
58-59
60
61
62
63-64
65
66-70
71
72
73-80
81
82-98
99

DEFINITIONS
Pharmacy
Unassigned
School
Homeless Shelter
Indian Health Service Free-standing Facility
Indian Health Service Provider-based Facility
Tribal 638 Free-standing Facility
Tribal 638 Provider-based Facility
Prison Correctional Facility
Unassigned
Office
Home
Assisted Living Facility
Group Home
Mobile Unit
Temporary Lodging
Walk-in Retail Health Clinic
Place of Employment-Worksite
Unassigned
Urgent Care Facility
Inpatient Hospital
Outpatient Hospital
Emergency Room Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Unassigned
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Unassigned
Ambulance (Land)
Ambulance (Air or Water)
Unassigned
Independent Clinic
Federally Qualified Health Center
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
Community Mental Health Center
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Center
Psychiatric Residential Treatment Center
Non-residential Substance Abuse Treatment Facility
Unassigned
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
Unassigned
End-Stage Renal Disease Treatment Facility
Unassigned
Public Health Clinic
Rural Health Clinic
Unassigned
Independent Laboratory
Unassigned
Other Place of Service

Note: For more information on Place of Service Codes, see the National
Uniform Claim Committee’s website at www.nucc.org.

Instructions and Examples of
Supplemental Information in
Item Number 24
The following are types of supplemental information that can be entered
in the shaded areas of Item Number 24:
•
•
•
•

Narrative description of unspecified codes
National Drug Codes (NDC) for drugs
Contract rate
Tooth numbers and areas of the oral cavity

The following qualifiers are to be used when reporting these services.
ZZ
N4
CTR
JP
JO

Narrative description of unspecified code
National Drug Codes (NDC)
Contract rate
Universal/National Tooth Designation System
ANSI/ADA/ISO Specification No. 3950-1984 Dentistry Designation
System for Tooth and Areas of the Oral Cavity

For additional information for reporting NDC units, see the
National Uniform Claim Committee’s website at www.nucc.org.

Reminders
Complete all required fields. Make certain to enter the
following identifying information:
• Put the insured’s alpha prefix and identification number
in Field 1a.
• Put the insured’s policy group number in Field 11.
• Put the physician or supplier’s billing name, address,
ZIP code, telephone number and NPI number in Field 33.
The information required to file electronic claims is the same as for paper
claims but there are major advantages to submitting electronic claims
versus paper claims:
• You will reduce your overhead, electronically submitted
claims can save hours of clerical time.
• You have better control and accuracy. Electronic claims
are entered in the BCBSIL’s system just the way they leave
your office.
• You know when your claims are received because your
office receives special reports detailing which claims were
accepted. If there is a problem with your claim, you can
correct it before the claim is processed.
To obtain more information on electronic claim filing,
call 800-746-4614 or log on to bcbsil.com.

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CMS 1500 Billing Guide

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