Reference

CMS-1500 Field Reference (Fields 1–33)

Definitions for every field on the CMS-1500 (02/12) form, derived from the National Uniform Claim Committee (NUCC) manual.

• 1
  Insurance Program

  Indicate the type of health insurance coverage applicable to this claim by checking the appropriate box.

• 1a
  Insured's ID Number

  Enter the insured's ID number as shown on the insured's identification card for the payer to which the claim is being submitted.

• 2
  Patient's Name

  Enter the patient's full last name, first name, and middle initial as shown on the insurance card.

• 3
  Patient's Birth Date & Sex

  Enter the patient's 8-digit birth date (MM|DD|CCYY) and select sex.

• 4
  Insured's Name

  Enter the insured's full last name, first name, and middle initial. If the insured is the same as the patient, enter SAME.

• 5
  Patient's Address

  Patient's address: street, city, state, ZIP, and telephone number. No punctuation.

• 6
  Patient Relationship to Insured

  Check the box for the patient's relationship to insured when item 4 is completed.

• 7
  Insured's Address

  Enter the insured's address and telephone number. If same as patient, enter SAME.

• 8
  Reserved for NUCC Use

  Field is reserved for NUCC use. Leave blank.

• 9
  Other Insured's Name

  Last name, first name, middle initial of the other insured if there is another health benefit plan.

• 9a
  Other Insured's Policy/Group No.

  Enter the policy or group number of the other insured.

• 9b
  Reserved for NUCC Use

  Field is reserved for NUCC use. Leave blank.

• 9c
  Reserved for NUCC Use

  Field is reserved for NUCC use. Leave blank.

• 9d
  Insurance Plan Name / Program Name

  Enter the other insured's insurance plan or program name.

• 10a
  Condition Related to Employment?

  Indicate whether the patient's condition is related to employment.

• 10b
  Auto Accident?

  Indicate whether the condition is related to an auto accident. If yes, enter the state.

• 10c
  Other Accident?

  Indicate whether the condition is related to another type of accident.

• 10d
  Claim Codes (Designated by NUCC)

  Enter applicable claim codes designated by NUCC (e.g., condition codes for Medicaid).

• 11
  Insured's Policy Group or FECA Number

  Enter the insured's policy group or FECA number as it appears on the insured's healthcare ID card.

• 11a
  Insured's Date of Birth & Sex

  Enter the 8-digit date of birth and sex of the insured.

• 11b
  Other Claim ID (Designated by NUCC)

  Enter the qualifier identifier in the left-hand side and the Other Claim ID in the right.

• 11c
  Insurance Plan Name or Program Name

  Enter the name of the insurance plan or program of the insured.

• 11d
  Is there another Health Benefit Plan?

  If yes, complete items 9, 9a, and 9d.

• 12
  Patient's or Authorized Person's Signature

  Patient's authorization to release medical information necessary to process the claim. Enter 'Signature on file' or signature.

• 13
  Insured's or Authorized Person's Signature

  Insured's authorization for payment of medical benefits to the provider.

• 14
  Date of Current Illness, Injury, or Pregnancy (LMP)

  Date of the first symptom of current illness, date of accident, or date of LMP. Include qualifier (431=onset, 484=LMP).

• 15
  Other Date

  Enter another date related to the patient's condition or treatment with applicable qualifier.

• 16
  Dates Patient Unable to Work in Current Occupation

  Enter the from/through dates the patient is unable to work, if applicable.

• 17
  Name of Referring Provider or Other Source

  Enter the name and qualifier of referring, ordering, or supervising provider.

• 17a
  Other ID #

  Enter the non-NPI ID of the referring provider with qualifier (e.g., 1G, G2).

• 17b
  Referring NPI

  National Provider Identifier of the referring/ordering/supervising provider. Validated as 10 digits with Luhn checksum.

• 18
  Hospitalization Dates Related to Current Services

  Inpatient admission/discharge dates related to the services billed.

• 19
  Additional Claim Information (Designated by NUCC)

  Identify additional information about the claim as designated by NUCC.

• 20
  Outside Lab? & Charges

  Indicate if lab services were performed by an outside lab and the related charges.

• 21
  Diagnosis or Nature of Illness or Injury (ICD-10)

  Up to 12 ICD-10-CM diagnosis codes (A–L) relating to services. Include ICD indicator (0=ICD-10).

• 22
  Resubmission Code & Original Ref. No.

  Code identifying resubmission, plus the original reference number for resubmitted claims.

• 23
  Prior Authorization Number

  Enter any prior authorization, referral, CLIA, or mammography pre-cert number.

• 24
  Service Lines (24A–24J)

  Up to 6 lines of services. Each line: dates, POS, EMG, CPT/HCPCS + modifiers, diagnosis pointer, charges, units, EPSDT, rendering provider NPI.

• 25
  Federal Tax I.D. Number

  Provider's federal tax ID (SSN or EIN); check appropriate box.

• 26
  Patient's Account No.

  Provider's internal patient account number.

• 27
  Accept Assignment?

  Indicate whether the provider accepts assignment of Medicare benefits.

• 28
  Total Charge

  Sum of charges in 24F for all service lines.

• 29
  Amount Paid

  Amount the patient or other payer paid toward the covered services only.

• 30
  Reserved for NUCC Use

  Field is reserved for NUCC use. Leave blank.

• 31
  Signature of Physician or Supplier

  Signature of provider or representative and the date signed.

• 32
  Service Facility Location Information

  Name and address where services were rendered, plus NPI (32a) and other ID (32b).

• 33
  Billing Provider Info & Phone #

  Billing provider's name, address, phone, NPI (33a) and other ID (33b).