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Last Modified: 5/11/2018 Location: FL, PR, USVI Business: Part B

CMS-1500 (02/12) data element requirements

The following information discusses the conditions and requirements of the item fields within the CMS-1500 (02/12) paper claim form.
The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.
Click here external pdf file to view a sample of the form
Note: If submitting paper claim forms, ensure to use only original red and white forms. Black and white copies will be returned as unprocessable.
Status Key:
R = Completion of this item is required by Medicare for every claim
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare
Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.
Note: Providers can utilize the First Coast Service Options Inc. (First Coast) ABILITY | PC-ACE™ software to submit claims electronically. ABILITY | PC-ACE™ software has built-in edits to avoid submitting claims without required information being included. Click here for additional information on ABILITY | PC-ACE™.
Some item numbers contain links to First Coast provider resources, providing additional information.

Item Number
Item Description and Guidance
Requirement Status
1
Type of insurance
R
1a
R
2
Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card.
R
3
Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex.
R
4
Insured’s name
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.)
C
5
Patient’s mailing address, city, state, and phone number
R
6
Check appropriate box for patient’s relationship to insured.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.)
C
7
Insured’s address and telephone number.
Note
: When address is the same as patient’s, enter the word SAME.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.)
C
8
Leave blank -- Medicare Part B Providers are not required to complete.
NR
9-9d
Medigap information (Leave Items 9b and 9c blank)
C
10a-c
Employment/accident indicators
R
10d
C
Primary insurance policy number
Note
: Enter the word NONE if Medicare is primary
R
Insured’s birth date, employer, plan name (Item 11b -- provide this information to the right of the vertical line.)
C
Another health benefit plan
Leave blank -- Medicare Part B Providers are not required to complete.
NR
12
Patient’s signature and date
R
13
Patient signature -- Medigap authorization
Note
: Must be completed if information contained in 9-9d.
C
14
Date of current illness, injury, or pregnancy
Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14.
C
15
Leave blank -- Medicare Part B Providers are not required to complete.
NR
16
If patient is employed, enter dates patient will be unable to work in current occupation.
C
Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
DN -- referring provider
DK -- ordering provider
DQ -- supervising provider
Enter the qualifier to the left of the dotted vertical line on item 17.
Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
See also the Ordering/referring provider FAQs for additional guidance.
C
Required if services are ordered, referred or supervised
DO NOT complete
NR
If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
(Click here to verify the provider's NPI is eligible to order or refer services.)
C
Required if services are ordered, referred or supervised
18
Hospitalization dates
C
19
Additional claim information
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 external pdf file for guidance on completion of Item 19
C
20
Outside lab
See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services.
C
Report up to twelve primary diagnosis codes
For dates of service prior to October 1, 2015 -- report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
For dates of service on and after October 1, 2015 -- report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
R
22
Leave blank -- Medicare Part B Providers are not required to complete.
NR
23
Prior authorization number
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 external pdf file for guidance.
C
24A
Date(s) of service (DOS)
R
R
24C
Leave blank -- Medicare Part B Providers are not required to complete.
NR
24D
R
Diagnosis pointer
Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line.
R
24F
Charge (in dollars) for service
R
24G
Days/Units
R
24H
Leave blank -- Medicare Part B Providers are not required to complete.
NR
24I
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Enter the NPI of the rendering provider in the lower non-shaded portion.
Do not report anything in the upper shaded portion of item 24J.
C
25
Federal tax identification number (TIN)
C
26
Patient’s account number
C
27
Assignment
See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1 external pdf file for list of provider and claim types for which assignment must always be accepted.
R
28
Total Charges
R
29
Enter amount collected from patient, if any.
Note
: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
C
30
Leave blank -- Medicare Part B Providers are not required to complete.
NR
31
Provider signature and date
Note:
"Signature on File" and/or a computer generated signature are acceptable. See CMS IOM Pub. 100-04, chapter 26, section 10.4 Item 32 external pdf file for details
R
For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
Name, address and ZIP of location where services were rendered for all locations.
Note:
As of January 1, 2011, all locations (including patient's home) must be reported.
R
If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
Note: Effective on or after April 1, 2015, for reference laboratory and anti-markup claims, billing physicians and suppliers are required to report the name, address, ZIP code, and NPI of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Physicians and other suppliers will no longer be permitted to submit their own NPI in Item 32a (or its electronic equivalent) when the performing physician or supplier is located in another jurisdiction.
Example 1 (Puerto Rico): If a San Juan provider purchases a service performed by a provider in San Sebastian, the San Sebastian provider's address and NPI should be reported.
Example 2 (Florida): If a Jacksonville, Florida provider purchases a diagnostic service from a mobile provider located in Kingsland, Georgia, they would report the physical location and NPI of the provider where services were performed (Kingsland, GA).
C
32b
DO NOT complete
NR
Billing provider’s name, address, ZIP and telephone number
R
Enter the NPI of the billing provider or group.
R
DO NOT complete
NR
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.