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Printed Date: 9/22/2015
The following instructions have been developed as a guide for submitting the CMS-1500 claim form to Palmetto GBA.
Dot Matrix Printers
Palmetto GBA will no longer accept paper claims printed on dot matrix printers. Paper claims are scanned and electronically entered into our processing system, and dot matrix printers produce type that is very light, which causes delays in processing your claims.
Even if you qualify to submit paper claims, consider submitting electronically. Electronic claims are processed more quickly, and you will generally receive reimbursement sooner than if you submit paper claims. Please contact our EDI Technology Support Center for more information.
Why use the CMS-1500 Claim Form?
The CMS-1500 claim form answers the needs of many insurers. It is the basic form prescribed by the Centers of Medicare & Medicaid Services (CMS) for the Medicare program for claims from physicians and suppliers.
The revised version of the CMS 1500 claim form is version 02/12 and is approved under the OMB control number 0938-1197.
Reminder: The Administrative Simplification and Compliance Act (ASCA) prohibits Medicare from making payments on claims not submitted electronically on or after October 16, 2003, unless a provider is small (fewer than 10 full-time equivalent employees for providers required to bill Medicare carriers) or meets one of the very few limited exceptions to this requirement.
You must submit your claims electronically unless you meet the exceptions criteria established by ASCA.
If you qualify to submit paper claims, follow these instructions when completing your CMS-1500 claim forms:
Preparing the CMS-1500 Claim Form
Palmetto GBA scans claim information from the CMS-1500 claim form into the processing system. Successful scanning begins with the proper submission of claim data. It is important that claims be submitted with proper and legible coding. Claims that are not legible or properly coded will be returned or rejected.
Please follow these helpful hints when completing your CMS-1500 forms:
The font should be:
The font must not have:
Do not submit paper claims with:
The claim form must be:
Claims Submitted with Multiple Pages
Do not complete Item 28 for each CMS-1500 claim form. The total for Item 28 must be completed on the last CMS-1500 claim form. This only applies when there are more than six detail lines for one claim.
If multiple CMS-1500 claim forms are submitted with totals on each claim form, the claims will be scanned as separate claims and not as multi-page claim.
Employer's Name or School Name:
Leave blank if item 9d is completed. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card. For example:
1257 Anywhere Street
Baltimore, MD 21204
is shown as "1257 Anywhere St. MD 21204.
Diagnosis or Nature of Illness or Injury:
Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (e.g., PA, NP, CNS, CRNA) use an ICD-9-CM or ICD-10-CM code number and code to the highest level of specificity for the date of service. Enter up to four diagnosis codes.
If the diagnoses are not submitted as indicated, there will be a possibility that the diagnoses will not be processed correctly or accepted.
All narrative diagnoses for non-physician specialties shall be submitted on an attachment.
Only ICD-9-CM or ICD-10-CM code numbers should be listed in Item 21. Narrative descriptions/diagnoses could cause the claim to deny.
For form version 02/12, it may be appropriate to use either ICD-9-CM or ICD-10-CM codes depending upon the dates of service.
The 'ICD Indicator' identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:
Indicator Code Set
9 ICD-9-CM diagnosis
0 ICD-10-CM diagnosis
Enter the indicator as a single digit between the vertical, dotted lines.
Do not include ICD-9 and ICD-10 codes on the same claim form. Separate claim forms must be submitted when reporting both an ICD-9 code and an ICD-10 code.
Enter up to 12 diagnosis codes. The diagnosis codes are to be entered on the lines with letters A-L. Relate lines A-L to the lines of service in 24E by the letter of the line.
Do not insert a period in the ICD-9 or ICD-10 code.
PRIOR AUTHORIZATION NUMBER:
Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
Enter the 7-digit Investigational Device Exemption (IDE) number when an investigational device is used in a FDA-approved clinical trial.
For physicians performing care plan oversight services, enter the 6-digit Medicare provider number of the home health agency (HHA) or hospice when HCPCS code G0181 (HH) or G0182 (Hospice) is submitted. NOTE: This requirement is waived at this time and claims for these services will be rejected if the number is submitted.
Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures. Refer to the CMS CLIA web page for more information.
Ambulance providers must enter the 5-digit zip code for the point of pickup.
Enter the prior authorization number for services subject to prior authorization.
Enter the diagnosis code reference number or letter as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter per line item. When multiple services are performed, enter the primary reference number/letter for each service. When using the CMS 1500 claim form version 02/12, the reference to supply in 24E will be a letter from A-L.
If a situation arises where two or more diagnoses are required for a procedure code (e.g., Pap smears), reference only one of the diagnoses in item 21.
Days or Units:
Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures). When multiple services are provided, enter the actual number provided.
For anesthesia, show the elapsed time (minutes) in item 24g. Convert hours into minutes and enter the total minutes required for this procedure.
For instructions on submitting units for oxygen claims, see Pub. 100-04, Chapter 20, Section 130.6 (PDF, 478 KB).
Beginning with dates of service on and after January 1, 2011, for ambulance mileage, enter the number of loaded miles traveled rounded up to the nearest tenth of a mile up to 100 miles. For mileage totaling 100 miles and greater, enter the number of covered miles rounded up to the nearest whole number miles. If the total mileage is less than 1 whole mile, enter a “0” before the decimal (e.g. 0.9). See Pub. 100-04, chapter 15, §20.2 for more information on loaded mileage and §30.1.2 for more information on reporting fractional mileage.
Name and Complete Address of Facility (Including ZIP Code) Where Services Were Rendered:
Enter the name, address and zip code of the facility if the services were furnished in a hospital, clinic, laboratory, facility, physician’s office or patients home.
Effective January 1, 2011: For claims processed on or after January 1, 2011, submission of the location where the service was rendered will be required for all POS codes.
Only one name, address and ZIP code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted.
Providers of service (namely physicians) shall identify the supplier's name, address and ZIP Code when billing for anti-markup tests. When more than one supplier is used, a separate form CMS-1500 shall be used to bill for each supplier. See Pub. 100-04, Chapter 1, Section 10.1.1.2 (PDF, 1 MB) for more information on payment jurisdiction for claims subject to the anti-markup limitation.
Note: A P.O. Box is not an acceptable address.
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in Chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.
If a modifier is submitted, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home. Refer to the CMS HPSA/PSA Web page for more information.
If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.
Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.
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Last Updated: 07/05/2018