Interactive CMS-1500 Claim Form Instructions
 
How to use the Interactive Claim Form:
  • Click on a item on the form below to view detailed electronic and paper instructions.
  • The following instructions apply to both electronic and paper claim submitters. Instructions include requirements for each item of the CMS-1500 claim form.
Before using the Interactive Claim Form
Review the CMS Claim Filing Instructions article on the Palmetto GBA Web site. This article contains instructions that should be used as a guide to prepare, complete and submit the CMS-1500 claim form. To access this article, select:
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CMS-1500 claim form header spacer
Left Side of CMS-1500 Claim Form Item 1: Type of Health Insurance Item 1a: Insured's I.D. Number Right Side of CMS-1500 Claim Form spacer
Item 2: Patient's Name Item 3: Patient's Birth Date Item 4: Insured's Name spacer
Item 5: Patient's Address Item 6: Patient's Relationship To Insured Item 7: Insured's Address spacer
Item 8: Patient Status spacer
Item 9, 9a, 9b, 9c, 9d: Other Insured's Name, Policy Number, Date of Birth, Employer's Name/School, & Insurance Plan Name/Program Name Item 10: Is The Patient's Condition Related To Employment, Auto Accident, or Other Accident? Item 11, 11a, 11b, 11c, 11d: Insured's Policy Number, Date of Birth, Employer's Name/School, & Is There Another Health Benefit Plan spacer
Item 10d: Reserved For Local Use spacer
Item 12: Patient's or Authorized Person's Signature Item 13: Insured's or Authorzied Person's Signature spacer
Item 14: Date of current illness, injury, date of the initiation chiropractic course of treatment and x-ray date. Item 15: If The Patient Has Had Same Or Similar Services/ Illness - Give First Date Item 16: Dates Patient Unable To Work In Current Occupation spacer
Items 17, 17a, & 17b: Referring Physician Or Other Source Information Item 18: Hospitalization Dates Related To Current Services spacer
Item 19: Reserved for Local Use Item 20: Outside Lab - Charges spacer
Item 21: Diagnosis or Nature or Illness or Injury Item 22: Medicaid Resubmission Code spacer
Item 23: Prior Authorization Number spacer
Item 24a: Claim Detail Information Items 24b: Place of Service Item 24c: Type of Service Item 24d: Providers, Services, or Supplies Item 24e: Diagnosis Code Item 24f: Charges Item 24g: Days or Units Item 24h: EPSDT Family Plan Item 24i: Legacy Qualifier Rendering Provider Item 24j: Legacy Provider Number (PTAN)/NPI Rendering Provider spacer
Item 25: Federal Tax I.D. Number Item 26: Patient's Account Number Item 27: Accept Assignment Item 28: Total Charges Item 29: Amount Paid Item 30: Balance Due spacer
Item 31: Signature of Physician or Supplier Item 32, 32a, & 32b: Name & Complete Address of Facility (Including Zip Code) Where Services Were Rendered Items 33, 33a, & 33b: Physician's/Supplier's Billing Information spacer
Footer of CMS-1500 Claim Form spacer


CPT codes, descriptions, and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.