Completing CMS-1500 Claim Form

This section incorporates information from the National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual for the 08/05 Version into the BlueCare Provider Administration Manual to help provide information on how to complete claim forms in compliance with Centers for Medicare and Medicaid Services (CMS) regulations.

Included is a description of how each block of the CMS-1500 claim form is to be completed, what type of data should be entered, and the proper format for entering the data. Since detailed discussions or explanations of all the codes, rules and options go beyond the scope of this document, please refer any questions to the payor organization with which you are dealing.

Information and codes contained herein are accurate at the time of publication. Payor-issued mailings (newsletter, bulletins, etc.), workshop sessions and Provider Network Manager visits are sources of information for keeping this manual current.

To avoid delays in receiving payments and to avoid unnecessary claim denials, it is important that all of the required information is provided in the specified formats.

The printing specification sections are among the most important parts of this manual. The CMS-1500 form makes it possible for payors to continue adding the use of Optical Character Recognition equipment to their claims entry operations, making faster and more accurate claim payments possible. However, incomplete data, or data not properly aligned in the proper block will be rejected by OCR equipment, creating delays in processing or the return of the claim for correction and resubmission.

The following general instructions are intended to be a guide only for completing the CMS-1500 claim form. Providers should refer to the most current federal, state, or other payer instructions for specific requirements applicable to the 1500 Claim Form. The 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version can be found on the National Uniform Claim Committee (NUCC) Web site, www.nucc.org.

1. General Instructions

The form designated CMS-1500 is approved by CMS, TRICARE/CHAMPUS on Medical Services, and BlueCross BlueShield of Tennessee.

A summary of suggestions and requirements needed to complete the CMS-1500 claim form follows:

Only one line item of service per claim line (Block #24) can be reported. If more than 6 lines per claim are needed, additional claim forms will be required.

“Super bills,” statements, computer printout pages, or other sheets listing dates, service, and/or charges cannot be attached to the CMS-1500 claim form.

The form is aligned to a standard typing format of 10 pitch (PICA) or standard computer-generated print of 10 characters per inch. Vertical spacing is 6 lines per inch.

The form is designated for double spacing with the exception of Blocks #31, 32 and 33, which may be single-spaced.

Use standard fonts: do not intermix font styles on the same claim form. Do not use italics and script on the form.

In completing all claim information COLOR OF INK should be as follows: 1. Computer generated color of black

2. Manual typewriter standard of Sinclair and Valentine J6983 Use upper case (CAPITAL) letters for all alpha characters.

Do not use dollar signs ($), decimals (.), or commas (,) in any dollar amount blocks. Enter information on the same horizontal plane.

Enter all information within the boundaries of the designated block.

Extraneous data (handwritten or stamped) may not be printed on the form except to mark as “Corrected Bill”.

Pin feed edges should be evenly removed prior to submission. Rev 12/06

Form Alignment

The CMS-1500 is designed for printing or typing 6 lines per inch vertically and 10 characters per inch horizontally. On the title line of the form above Block #1 and Block #1A are 6 boxes labeled “PICA”. These boxes should be considered Line 1, Columns 1,2 and 3, and Line 1, Columns 77,78 and 79. Form alignment can be verified by printing “X’s” in these boxes.

Entering All Dates

In Blocks 3, 9B, and 11A please include a space between each digit. The blank space should fall on the vertical lines provided on the form.

Unless otherwise indicated, all date information should be shown in the following format:

For Blocks 3, 9B, and 11A MMblankDDblankCCYY MM=month (01-12) 1 blank space DD=day (01-31) 1 blank space CC=century (20, 21) YY=year (00-99)

The blank space should fall on the vertical lines provided on the form. Do NOT exclude leading zeros in the date fields.

(Correct: January 1, 1924 = 01 01 24; Incorrect: 1124).

Note: New requirement for Block 24A. Omit spaces in Field 24A (date of service). By entering a continuous number, the date(s) will penetrate the dotted vertical lines used to separate month, day, and year. This is acceptable. Ignore the dotted vertical lines without changing font size.

For Block 24A MMDDCCYY MM=month (01-12) DD=day (01-31) CC=century (20, 21) YY=year (00-99)

2. Physical Claim Form Specifications

While CMS-1500 claim forms can be ordered from the Government Printing Office, some providers may elect to deal with independent form vendors. All CMS-1500 claim forms must conform to the following print specifications:

PAPER

OCR bon - JCP25 20 pound

217 mm x 281mm (+ or - 2mm)

Cut square, corners 90 degrees (+ or -.025)

INK

Standard is Sinclair and Valentine J6983 Same ink front and back of form

Multi-part forms must have same ink on all copies Rev 12/06

MARGIN

Top to typewriter alignment bar is 34mm Right to left margin is 9mm

ASKEWITY

No greater than .15mm in 100mm

X and Y OFFSET for MARGINS must not vary by more than + or - 0.010 inches from page to page (x= horizontal distance form left margin to print, y= vertical distance from top to print).

NO MODIFICATIONS may be made to the CMS-1500 without the prior approval of the Centers for Medicare and Medicaid Services.

3. Form Contents and Description

Below is a description of each block on the form with print specifications for completing each area.