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Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim.

Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

used for Medicare only. It is used when a physician pays an outside entity to perform a service. If the physician has an agreement to pay for the service himself and he wants to be reimbursed for the service, he will mark "yes" and enter the amount he paid for it.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

Field by Field Explanation Of The CMS-1500 Form a. ... PATIENT NAME from Patient Master. Patient DOB and SEX from Patient Master. Name of the INSURED PERSON of the destination payer in Insurance Information screen under Patient Master. PATIENT ADDRESS, CITY, STATE, ZIP CODE & HOME PHONE from Patient Master.

Box 23 - TITLE: Prior Authorization Number (this field is also used for CLIA numbers) • INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

The CMS-1500 claim form is used to submit non-institutional claims for health care services to many private payers, Medicare, Medicaid and other government health insurance programs.

If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

used for Medicare only. It is used when a physician pays an outside entity to perform a service. If the physician has an agreement to pay for the service himself and he wants to be reimbursed for the service, he will mark "yes" and enter the amount he paid for it.

KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim Field IDField DescriptionData Type24SHADED AREA – SUPPLEMENTAL INFORMATION24aDATE(S) OF SERVICER24bPLACE OF SERVICER24cEMGS59 more rows

Field by Field Explanation Of The CMS-1500 Form a. ... PATIENT NAME from Patient Master. Patient DOB and SEX from Patient Master. Name of the INSURED PERSON of the destination payer in Insurance Information screen under Patient Master. PATIENT ADDRESS, CITY, STATE, ZIP CODE & HOME PHONE from Patient Master.

Box 21: This box requires the details of the diagnosis or the nature of the illness of the patient. Enter the diagnosis code and the primary reason for providing the services.

Box 23 - TITLE: Prior Authorization Number (this field is also used for CLIA numbers) • INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

9. Name of the INSURED PERSON of other payer in Insurance Information screen under Patient Master.

The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers.

The CMS-1500 claim form is used to submit non-institutional claims for health care services to many private payers, Medicare, Medicaid and other government health insurance programs.

The non-institutional providers and suppliers who can use the CMS-1500 form to bill medical claims include Ambulance services, Clinical social workers, Physicians and their assistants, Nurses including clinical nurse specialists and practitioners, Psychologists, etc. The form is usually not hospital-focused.

If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim Field IDField DescriptionData Type24SHADED AREA – SUPPLEMENTAL INFORMATION24aDATE(S) OF SERVICER24bPLACE OF SERVICER24cEMGS59 more rows

Box 21: This box requires the details of the diagnosis or the nature of the illness of the patient. Enter the diagnosis code and the primary reason for providing the services.

9. Name of the INSURED PERSON of other payer in Insurance Information screen under Patient Master.

The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers.

The non-institutional providers and suppliers who can use the CMS-1500 form to bill medical claims include Ambulance services, Clinical social workers, Physicians and their assistants, Nurses including clinical nurse specialists and practitioners, Psychologists, etc. The form is usually not hospital-focused.