CMS-1500 (02/12) data element requirements
The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.
- 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 PC-ACE software to submit claims electronically. PC-ACE software has built-in edits to avoid submitting claims without required information being included. View additional information on PC-ACE.
Some item numbers contain links to First Coast provider resources, providing additional information.
| Item number | Item description and guidance | Requirement status | 837P professional version 5010 / 5010A1 |
|---|---|---|---|
| 1 | Type of insurance | R |
|
| 1a | Patient’s Medicare ID | 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 | Other insured’s name | C |
|
| 9a | Other insured’s policy group number | C |
|
| 9b | Leave blank - reserved for NUCC use (previously "Other insured’s date of birth, sex") | NR |
|
| 9c | Leave blank if item 9d is completed - reserved for NUCC use (previously "Employer’s name or school name") | NR |
|
| 9d | Insurance plan name or program name | C |
|
| 10a-c | Employment / accident indicators | R |
|
| 10d | Medicaid ID | C |
|
| 11 | Primary insurance policy number Note: Enter the word NONE if Medicare is primary. |
R |
|
| 11a | Insured’s date of birth, sex | C |
|
| 11b | Other claim ID (previously "Insured’s employer name or school name") | C |
|
| 11c | Insurance plan name or program name | C |
|
| 11d | 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 |
|
| 17 |
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.
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 related FAQs on the First Coast provider website for additional details for reporting referring / ordering providers. See also the Part A and B provider enrollment FAQs for additional guidance. |
C Required if services are ordered, referred, or supervised |
|
| 17a | DO NOT complete | NR |
|
| 17b | If the service is referred or ordered, enter the National Provider Identifier (NPI) of the referring / ordering individual provider only. |
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 for guidance on completion of Item 19. |
C |
|
| 20 | Outside lab See claim related FAQs on the First Coast provider website for additional details for reporting purchased services. |
C |
|
| 21 |
Report up to 12 primary diagnosis codes
|
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 for guidance. |
C |
|
| 24A | Date(s) of service (DOS) | R |
|
| 24B | Place of service (POS) See CMS IOM Pub 100-04, Chapter 26, section 10.5 for codes and definitions. |
R |
|
| 24C | Leave blank - Medicare Part B providers are not required to complete. | NR |
|
| 24D | Procedure code / applicable modifiers | R |
|
| 24E |
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 Note: The maximum number of characters to be submitted in the dollar amount field is seven characters. Claims exceeding 99,999.99 will be rejected. For total charge amounts exceeding 99,999.99, the claim must be split into separate claims. When splitting the charge of the service, be sure the dollar amounts are slightly different, as this will prevent the system from assuming the two claims are an exact duplicate. |
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 |
|
| 24J |
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 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 for details. |
R |
|
| 32 |
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. |
R |
|
| 32a |
If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
|
C |
|
| 32b | DO NOT complete | NR |
|
| 33 | Billing provider’s name, address, ZIP code, and telephone number | R |
|
| 33a | Enter the NPI of the billing provider or group | R |
|
| 33b | DO NOT complete | NR |
|
References
- Claim related FAQs
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, section 30.2.9, 30.3.1, 80.3.2.1.1 and 80.3.2.1.2
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 26, section 10
- Change request (CR) 8509 - Form CMS-1500 instructions: revised for form version 02/12
- CR 8806 - Reporting the service location National Provider Identifier (NPI) on anti-markup and reference laboratory claims