CMS Claim Filing Instructions
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 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.
CMS-1500 Helpful Hints
The font should be:
- Legible (computerized or typed claims, laser printers are recommended)
- In black ink
- Courier or Arial in 10, 11 or 12 point font
- Capital letters
The font must not have:
- Dot matrix print
- Bold, script, italic or stylized font
- Broken characters
- Red ink
- Mini-font
Do not submit paper claims with:
- Liquid correction fluid changes
- Data touching box edges or data running outside of the numbered boxes
- More than six service lines per CMS-1500 claim form. Do not compress two lines of information on one line. If more than six service lines are required, see instructions listed below under "Claims Submitted with Multiple Pages."
- Information in the shaded area in 24a through 24h. These fields are not used by Medicare (exception: NDC for physician-administered drugs for Medicare/Medicaid patients).
- Narrative descriptions of procedure codes, modifiers or diagnosis codes
- Stickers or rubber stamps
- Data, mailing address or labels on the top portion of the CMS-1500 claim form
- Special characters (e.g., hyphens, periods, parentheses, dollar signs or ditto marks)
- Handwritten descriptions
- Superbills
The claim form must be:
- An original CMS-1500 printed in red drop out ink with the printed information on back. Photocopies are not acceptable.
- Size: 8 ½ x 11 with the printer pin-feed edges removed at the perforations
- Free from excessive creases or tears (do not fold or staple)
- Clean and free from stains, notations, strike-overs, crossed-out or highlighted information, liquid correction fluid, glue or tape
Attachment Reminders:
- All attachments must identify the patient’s name, Medicare ID number, date of service and other pertinent information
- Attachments must be a full page (8 ½ x 11)
- Operative reports, radiology reports, etc., should be submitted with paper claims only when either the coding guidelines indicate these reports are needed to process the service(s) or when a Medicare representative requests this additional information
- Medicare Secondary Paper claims: Only attach the summary notice from the primary insurer that specifically corresponds to the claim you are submitting
Internet Resources
- Palmetto GBA Interactive CMS-1500 Claim Form Instructions
- CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 26 (PDF, 596 KB)
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.
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Item
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Information
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|---|---|
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1
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Medicare:
Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box). |
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1a
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Insured's ID Number:
Enter the patient's Medicare ID number, whether Medicare is primary or secondary payer. |
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2
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Patient's Name:
Enter the patient's last name, first name and middle initial, if any, as shown on the patient's Medicare card |
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3
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Patient's Birthdate:
Enter the patient's 8-digit birth date (MM/DD/YYYY) and sex. |
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4
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Insured's Name:
If there is insurance primary to Medicare, either through the patient or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word 'Same'. If Medicare is primary, leave blank. |
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5
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Patient's Address:
Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP Code and phone number. |
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6
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Patient's Relationship to Insured:
Check the appropriate box to indicate the patient's relationship to the insured when Item 4 is completed. |
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7
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Insured's Address:
Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word "Same." Complete this item only when Items 4, 6 and 11 are completed. |
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8
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Patient Status:
Check the appropriate box for the patient's marital status and whether employed or a student. |
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9
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Other Insured's Name:
Enter the last name, first name and middle initial of the enrollee in a Medigap policy, if it is different from that shown in Item 2. Otherwise, enter the word "Same." If no Medigap benefits are assigned, leave blank. Note: Only participating physicians and suppliers are to complete Item 9 and its subdivisions, and only when the patient wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier. Participating physicians and suppliers must enter information required in Item 9 and its subdivision if requested by the patient. Participating physicians and suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a patient elects to assign his or her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. See Pub. 100-04, Chapter 28 (PDF, 619 KB) of the CMS Internet Only Manual. Medigap: A Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in Section 1882 (g) (1) of Title XVIII of the Social Security Act and the definition contained in the NAIC Model Regulation, which is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the gaps in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members. Do not list other supplemental coverage in Item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim. |
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9a
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Other Insured's Policy or Group Number:
Enter the policy and/or group number of the Medigap enrollee preceded by Medigap, MG or MGAP. Note: Item 9d must be completed if you enter a policy and/or group number in Item 9a. |
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9b
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Other Insured's Date of Birth:
Leave blank. |
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9c
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Employer's Name or School Name: 1257 Anywhere Street is shown as "1257 Anywhere St. MD 21204." |
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9d
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Insurance Plan Name or Program Name:
Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID). Refer to IOM Pub. 100-04, chapter 28, section 70.6.4. |
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10a-10c
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Is the Patient's Condition Related to:
Check "Yes" or "No" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in Item 24. Enter the state postal code. Any items checked "Yes" indicate there may be other insurance primary to Medicare. Identify primary insurance information in Item 11. |
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10d
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Reserved for Local Use:
Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD. Currently, Palmetto GBA receives an eligibility tape from Medicaid. This procedure will continue, and this will not be a required item at this time. |
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11
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Insured's Policy Group or FECA Number:
This item must be completed. By completing this item, the physician or supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Important: This item must not be left blank or the claim will be rejected.
Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. See Pub. 100-05, Chapter 3, Medicare Secondary Payer Manual (PDF, 477 KB). |
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11a
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Insured's Date of Birth:
Enter the insured's 8-digit birth date (MM/DD/YYYY) and sex if different from Item 3. |
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11b
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Employer's Name or School Name:
Provide this information to the right of the vertical dotted line. |
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11c
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Insurance Plan Name or Program Name:
Enter the 9-digit Payer ID number for the primary insurer. If no Payer ID exists, then complete insurance primary payer's program or plan name (e.g., Blue Shield of [state]). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in Item 11. |
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11d
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Is There Another Health Benefit Plan?
Leave blank. Not required by Medicare. |
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12
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Patient's or Authorized Person's Signature:
The patient or authorized representative must sign and enter either a six-digit date (MM/DD/YY), eight-digit date (MM/DD/YYYY) or an alphanumeric date (e.g., January 1, 2009) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician or supplier file in accordance with Chapter 1, "General Billing Requirements." If the patient is physically or mentally unable to sign, a representative as specified in Pub. 100-04, Chapter 1, "General Billing Requirements," may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by the word "by," the representative's name, address, relationship to the patient and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient's representative revokes this arrangement. The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier, when the provider of service or supplier accepts assignment of the claim. Signature by mark (X): When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark. |
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13
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Insured's or Authorized Person's Signature:
The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 and its subdivisions. The patient or his or her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider or service or supplier's office must be insurer specific. It may state that the authorization applies to all services until it is revoked. |
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14
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Date of Current:
Enter either an eight-digit (MM/DD/YYYY) or six-digit (MM/DD/YY) date of current illness, injury or pregnancy. For chiropractic services, enter an eight-digit (MM/DD/YYYY) or six-digit (MM/DD/YY) date of the initiation of the course of treatment and enter an eight-digit (MM/DD/YYYY) or six-digit (MM/DD/YY) date of the X-ray to document subluxation in Item 19. |
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15
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If the Patient Has Had Same or Similar Services/Illness, Give First Date:
Leave blank. Not required by Medicare. |
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16
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Dates Patient Unable to Work in Current Occupation:
If the patient is employed and is unable to work in his/her current occupation, enter an eight-digit (MM/DD/YYYY) or six-digit (MM/DD/YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage. |
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17
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Name of Referring Physician or Other Source:
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate form CMS-1500 shall be used for each ordering/referring physician. Enter one of the following qualifiers as appropriate to identify the role that the physician (or nonphysician practitioner) is performing:
Qualifier: DN — Provider role: Referring Provider
Qualifier: DK — Provider role: Ordering Provider
Qualifier: DQ — Provider role: Supervising Provider
Enter the qualifier to the left of the dotted vertical line on Item 17.
The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:
Referring physician — a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering physician — a physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient. See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service. The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s NPI. The following services/situations require the submission of the referring/ordering provider information:
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17a
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ID Number of Referring Physician:
Leave blank |
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17b
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NPI Number of Referring Physician:
Enter the NPI of the referring/ordering physician listed in Item 17. Note: Field 17b is required when a service was ordered or referred by a physician. |
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18
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Hospitalization Dates Related to Current Services:
Enter either an eight-digit (MM/DD/YYYY) or a six-digit (MM/DD/YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization. |
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19
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Reserved for Local Use:
Enter either a six-digit (MM/DD/YY or an eight-digit (MM/DD/YYYY) date patient was last seen and the NPI of his or her attending physician when a physician providing routine foot care submits claims. For physical therapy, occupational therapy or speech-language pathology services, effective for claims with dates of service on or after June 6, 2005, the date last seen and the NPI of an ordering/referring/attending/certifying physician or nonphysician practitioner are not required. If this information is submitted voluntarily, it must be correct or it will cause rejection or denial of the claim. However, when the therapy service is provided incident to the services of a physician or nonphysician practitioner, then incident to policies continue to apply. For example, for identification of the ordering physician who provided the initial service, see Item 17 and 17b, and for the identification of the supervisor, see item 24J of this section. Enter either a six-digit (MM/DD/YY) or an eight-digit (MM/DD/YYYY) X-ray date for chiropractor services (if an X-ray, rather than a physical examination was the method used to demonstrate the subluxation). By entering an X-ray date and the initiation date for course of chiropractic treatment in Item 14, the chiropractor is certifying that all the relevant information requirements (including level of subluxation) of Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, are on file, along with the appropriate x-ray and all are available for carrier review. Enter the drug's name, dosage and National Drug Code (NDC) number when submitting a claim for not otherwise classified (NOC) drugs or radiopharmaceuticals. Enter a concise description of an "unlisted procedure code" or an NOC code if one can be given within the confines of this box. Otherwise, submit this information on an attachment to the claim. Enter all applicable modifiers when CPT modifier 99 (multiple modifiers) is entered in item 24d. If CPT modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and 'mod' represents all modifiers applicable to the referenced line item. CPT modifier 99 is only appropriate when more than four modifiers are necessary per line item. When only four modifiers apply, enter each modifier in the existing space in Item 24D. Enter the statement 'Homebound' when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services From Independent Labs, Physicians and Providers," and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of 'homebound' and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient. Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a non-participating physician or supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary. Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved. When dental examinations are billed, enter the specific surgery for which the exam is being performed. Note: A dental exam is covered for limited services when it is part of a comprehensive evaluation and management service. Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them. Enter a six-digit (MM/DD/YY) or an eight-digit (MM/DD/YYYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care. Note: The physician billing CPT modifier 54 will indicate the relinquished date of care and responsibility. The provider billing CPT modifier 55 will indicate the date the post-operative care and responsibility is assumed. Enter demonstration ID number "30" for all national emphysema treatment trial claims. You may voluntarily report the eight-digit National Library of Medicine (NLM) Clinical Trials Data Bank number for items and services provided in clinical trials that are qualified for coverage. The NLM number is not required at this time. Report this number with a "CT" prefix in Item 19 for paper claims only. For example: CT12345678. Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis. See Pub. 100-04, Chapter 8, Section 60.7.2 (PDF, 713 KB). Individuals and entities who bill carriers or A/B MACs for administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (slash), and the most current numeric test result figure up to 3 numerics and a decimal point[xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for Hematocrit tests: TR/R2/27.0. Note: Unless indicated on the previous pages, no other documentation is to be entered in Item 19 of the CMS-1500 claim form. Only the information, as listed on the previous pages, will be accepted in Item 19. Claims will be rejected if above instructions are not followed. |
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20
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Outside Lab Charges:
Complete this item when billing for diagnostic tests subject to the anti-markup payment limitation. Enter the acquisition price under charges if the "yes" block is checked. A "yes" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "no" check indicates "no anti-markup tests are included on the claim." When "yes" is annotated, item 32 shall be completed. When billing for multiple anti-markup tests, each test shall be submitted on a separate claim Form CMS-1500. When billing for multiple purchased diagnostic tests, each test shall be submitted on a separate claim Form CMS-1500. Note: This is a required field when billing for diagnostic tests subject to purchase price limitations. |
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21
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Diagnosis or Nature of Illness or Injury: 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 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. |
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22
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MEDICAID RESUBMISSION CODE:
Leave blank. Not required by Medicare. |
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23
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PRIOR AUTHORIZATION NUMBER: Enter the seven-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 six-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 five-digit ZIP Code for the point of pickup. Enter the prior authorization number for services subject to prior authorization. |
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24
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The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines. At this time, the shaded area in 24a through 24h is not used by Medicare. Future guidance will be provided on when and how to use this shaded area for the submission of Medicare claims.
When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g., N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space fill the remaining positions (e.g., UN2 or F2999999). |
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24A
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Date(s) of Service:
Enter a six-digit (MM/DD/YY) or eight-digit (MM/DD/YYYY) date for each procedure, service or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column 24G. |
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24B
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Place of Service:
Enter the appropriate place of service code(s) from the list provided in Pub. 100-04, Chapter 26, Section 10.5 (PDF, 596 KB). Identify the location, using a place of service code, for each item used or service performed. Note: When a service is rendered to a hospital inpatient, use the "inpatient hospital" code. |
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24C
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Type of Service:
Medicare providers are not required to complete this item |
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24D
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Procedures, Services or Supplies:
Enter the procedures, services or supplies using the CMS Health Care Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The form CMS-1500 has the ability to capture up to four modifiers. See Item 19 "CMS modifier 99" if you have more than four modifiers. Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment shall be submitted with the claim. |
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24E
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Diagnosis Code: 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. |
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24F
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Charges:
Enter the charge for each listed service |
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24G
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Days or Units: 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. |
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24H
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EPSDT Family Plan:
Leave blank. Not required by Medicare. |
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24I
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Legacy Qualifier Rendering Provider:
Enter the ID qualifier 1C in the shaded portion. |
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24J
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NPI Rendering Provider:
Enter the rendering provider’s NPI number in the lower portion. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower portion. This unprocessable instruction does not apply to influenza and pneumococcal vaccine claims submitted on roster bills as they do not require a rendering provider NPI.
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24K
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Reserved for Local Use:
There is no Item 24K on this version. |
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25
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Federal Tax ID Number:
Enter the provider of service or supplier Federal Tax ID (Employer Identification Number) or Social Security number. |
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26
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Patient's Account Number:
Enter the patient's account number assigned by the provider of service or supplier's accounting system. This field is optional to assist you in patient identification. |
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27
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Accept Assignment:
Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in Item 9 and Medigap payment authorization is given in Item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients. The following providers of service/suppliers and claims can only be paid on an assignment basis:
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28
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Total Charges:
Enter total charges for the services (i.e., total of all charges in item 24f). Note: 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.
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29
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Amount Paid:
Enter the total amount the patient paid on the covered services only. Note: This is not the amount the primary insurance paid.
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30
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Balance Due:
Leave blank. Not required by Medicare. |
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31
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Signature of Physician or Supplier:
Enter the signature of provider of service or supplier, or his/her representative, and either the six-digit date (MM/DD/YY), eight-digit date (MM/DD/YYYY), or alpha-numeric date (e.g., January 1, 2009) the form was signed. In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or nonphysician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in Item 31. When the ordering physician or nonphysician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in Item 31. |
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32
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Name and Complete Address of Facility (Including ZIP Code) Where Services Were Rendered: 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. For ambulance claims this block should be left blank. Ambulance providers refer to block 23.
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32a
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Facility NPI Number
Enter the NPI of the service facility. Providers of service (namely physicians) shall identify the supplier's NPI when billing for purchased diagnostic tests. |
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32b
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Facility Qualifier and Legacy
Leave Blank
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33
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Physician's Supplier's Billing Name, Address, ZIP Code and Phone Number:
Enter the provider of service/supplier's billing name, address, ZIP Code and telephone number. |
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33a
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Billing Provider NPI Number
Enter the NPI of the billing provider or group. |
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33b
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Billing Provider Qualifier and Legacy Number
Leave Blank |