Fillable Form CMS-1500

What is the CMS-1500 form?

The CMS-1500 form is the standard claim form used by physicians and allied health professionals to submit claims for medical services.

Can I fill out the CMS-1500 form?

If you are a physician or allied health professional, then you are eligible to submit claims for medical services by filling out this form.

What do I need to fill out the CMS-1500 form?

You will be needing information regarding your patient, insured, as well as the diagnosis.

First, you will need to know your patient’s insurance coverage applicable to this claim. The options are Medicare, Medicaid, Tricare Champus, CHAMPVA, Group Health Plan, FECA BLK LUNG, and others.They will also have to provide their ID number depending on what coverage is applicable.

You will be asked to provide your patient’s full legal name. This is composed of his or her last or family name, first or given name, middle initial, and suffix if one is present. If the patient is different from the insured, the insured must write down their full legal name as well.

You will also have to provide his or her current street address, along with their corresponding city, state, and ZIP code. Additionally, you must provide his or her telephone number as well, being sure to include the area code. If the patient is different from the insured, then the insured must write down the same details.

You will also be needing the patient’s date of birth as well as their biological sex. If the insured is different from the patient, then the insured must write down these same details. You must also indicate the patient’s marital and employment status.

Further, you will be needing any other insured’s name, policy or group number, date of birth, and biological sex, employer’s or school’s name, and insurance plan or program name. You will also need similar details for the insured.

You will also need to know what the patient’s condition is related to. You can indicate any of the following boxes: employment, auto-accident, or other accident. If the auto-accident box is ticked, you will be asked to indicate the state where the accident took place.

You will also be needing the insured’s policy group or FECA number. If there is another benefit plan, you will be asked to indicate so.

You will next need to place information regarding the diagnosis.

You will need the date of the current illness, injury, or pregnancy. If the patient has had similar illness in the past, please write the first date of said illness. You will also be asked to write the period of time where the patient was unable to work at their current job by indicating the from and to dates as well as the period of time where the patient was hospitalized.

You will next have to write the name of the referring provider or other source, as well as the NPI.

You must then indicate if there was an outside lab involved, as well as write down any monetary charges. Then, write down the medicaid resubmission code, original reference number, and prior authorization number.

Next, you will be needing the diagnosis or nature of illness or injury. You will also be needing the date(s) of service, place of service, EMG, procedures, services, or supplies, charges, days or units, EPSDT family plan, and rendering provider I.D. number.

In addition to all that, you will need the federal tax I.D. number, patient’s account number, total charge, amount paid, and balance due.

Finally, you will have to write down the service facility location information and billing provider information.

To finalize all information, the patient and insured must both affix their signatures in the designated space, as well as provide the date of signature. You, as the physician, must also indicate your signature and date of signature as well.

How do I fill out the CMS-1500 form?

We will be guiding you through the process of filling out the CMS-1500 form by giving you a step-by-step tutorial on how to properly accomplish the form.

Before attempting to answer any of the questions, read through the document and identify all the information that you will have to provide for the purpose of filling out this form. For your convenience, we have placed the list of information you will be needing in the section previous to this one.

This is a government document and as such it should be treated with the utmost level of care and attention.

Patient and Insured
First, indicate the patient’s insurance coverage applicable to this claim. You will have to check the box corresponding to their answer. The options are Medicare, Medicaid, Tricare Champus, CHAMPVA, Group Health Plan, FECA BLK LUNG, and others.

You must then write down the insured’s I.D. number. Indicate as well the patient’s relationship to the insured.

Following this, you will need to indicate both the insured and the patient’s full legal name composed of their last name, first name, and middle initial.Afterward, write both the insured and the patient’s date of birth and biological sex.

Next, you will have to write down the current addresses of both the patient and the insured. This includes listing details such as the town or city, state, and ZIP code. You will also be needing both of their telephone numbers.

You will then have to provide the other insured’s full legal name, date of birth, sex, employer’s or school’s name, insurance plan name or program name.

Next, indicate whether the patient’s condition was related to his or her current or previous employment, an auto accident, or another reason. If the patient’s condition is related to an auto accident, please indicate the state in which it happened.

Afterward, write the insured’s policy group or FECA number, employer’s or school’s name, insurance plan name or program name, and whether or not they have another health benefit plan.

To certify all information on this page, both the patient and the insured must affix their signatures and write down the date of signature.

Diagnosis
In this section, you will need to write information regarding the diagnosis.

First, write down the date of the current illness, injury, or pregnancy. Then, if the patient has had the same or similar illness previously, write down the first date of illness. Following this, write down the period of time wherein the patient was unable to work and a separate period for when they were hospitalized. Then, write down the name of the referring provider or other source.

If the patient was involved with an outside lab, they must indicate so along with any extra charges.

Then, write down the diagnosis or nature of illness or injury.

You will then need to write down your diagnosis or nature of illness or injury in the spaces provided. Follow this by writing their Medicaid resubmission code, original reference number, and prior authorization number.

Then, write down the following information in the provided spaces:

• Date(s) of service
• Place of service
• EMG
• CPT/HCPTS and Modifier
• Charges
• Number of Days or Units
• EPSDT Family Plan
• And Rendering Provider I.D. Number

For the last few items on this form, you will need your patient’s account number, federal tax number, total charge, amount paid, and balance due.

You will also need to write down the service facility’s location information as well as the billing provider information and phone number.

To certify all this information by affix your signature and the date of signature.

Once you have completed all of this, congratulations, you have successfully filled out the CMS-1500 form.