CMS 1500 Training 101
HP Enterprise Services
Learning Objective
• Welcome, this training presentation will educate you on how to complete a CMS 1500 claim
form; this includes a detailed explanation of all mandatory fields required for Vermont
Medicaid claim submissions.
Be sure to use the most current CMS 1500 Claim Form version, dated 08/05. Vermont Medicaid does not supply claim forms. Claim forms can purchased from office supply companies.
Unique ID
1a. INSURED’S ID NUMBER* Enter the Vermont Medicaid ID number as shown on the beneficiary’s Member ID card.
11d. IS THERE ANOTHER HEALTH BENEFIT PLAN* Check the appropriate box. If yes, complete fields 9 a-c.
X
Health benefits provided under Green Mountain Care are not considered other insurance. Other insurance only pertains to a private health insurance carrier.
Enter the Vermont Medicaid beneficiary's unique ID (UID). If you only have the social security number, you can get the UID by going to the transactions services production log in on our website, under business actions, select check eligibility status and enter their social security number
There are numerous fields on the claim form that do not need to be completed .
• Field 1a. Is the only required field.
• It is not required that you complete the address information in field 7.
• Field 11d. is required when the beneficiary has primary insurance.
• If the beneficiary has primary insurance , check
“yes” in field 11d and complete 9a, b and c.
Last Name, First Name
2. PATIENT’S NAME* Enter the beneficiary’s last and first name.
Completion of Field 2 is required, enter the beneficiaries last name and then first name. Spelling must be accurate, you can view how the beneficiaries name should appear by going to the VT Medicaid Portal at www.vtmedicaid.com under transaction services. There is no need to complete the address information in field 5.
X X X
10. CONDITION RELATED TO* Check appropriate box to indicate:
a. condition is related to employment b. condition is related to an auto accident
c. condition is related to any other type of accident.
If“YES” is checked in box: a, b or c; it is required to enter the accident date in field 14.
17b. NPI/REFERRING PROVIDER* Enter the referring provider’s NPI. Enter the prescribing NPI for independent lab and DME suppliers
(required field).
21. DIAGNOSIS CODE(S)* Enter the appropriate IDC-9-CM diagnosis code that relates to the service rendered. You may use up to four diagnosis codes (required field).
1234567890
401.9
If you are billing for a consultation code, enter the referring provider NPI in field 17b. If you are an independent lab or a durable medical equipment provider, enter the prescribing provider's NPI in 17b. Enter
a valid diagnosis codes in field 21.
24a. DATE(S) OF SERVICE* Enter the date of each service provided. If the From and To dates are the same, the To date is not required.
24b. PLACE OF SERVICE* Enter the appropriate two digit place of service code.
24d. PROCEDURE CODE* Enter the appropriate procedure code to explain the service rendered.
24e. DIAGNOSIS POINTER* Enter the appropriate diagnosis ‘pointer’ that relates to the service rendered (1 or 2 or 3 or 4) and corresponds to the diagnosis from field locator 21.
24f. CHARGES* Enter the usual and customary charge for the service rendered.
24g. DAYS OR UNITS* Enter the number of days or units of service which were rendered.
24j. ATTENDING PROVIDER* Enter attending physician’s NPI. Enter the billing provider NPI for
independent labs and DME suppliers. If Atypical, enter the 7-digit Vermont Medicaid ID number in the shaded area.
052512 11 99213 1 95 00 1 1234567890
Going across this section from left to right
• enter the date of service,
• the place of service,
• the procedure code (include modifiers if appropriate),
• the DX pointer,
• your usual and customary charge,
• the units,
• and the attending NPI.
Note - The taxonomy code is not required if the provider is not using their NPI to relate to more than one VT Medicaid provider number.
28. TOTAL CHARGE* Add the charges from field locator 24f for each line and enter the total in this field.
29. AMOUNT PAID* Enter the amount paid by other health insurance coverage, including contractual allowance if applicable (exclude Medicare payments). If this field is completed, field locators 11a, 11b and 11c must also be completed. Enter spend down if applicable.
Documentation must be attached if the services are not covered by the primary, or if the payment by the primary is $3.00 or less.
33. BILLING PROVIDER* Enter the payee provider name and address (Individual provider format: last name, first name)
33a. BILLING PROVIDER’S NPI* Enter the billing provider’s NPI.
Last Name, First Name Street Address
City, State, Zip code 1234567890
95.00
The contractual allowance is entered in field 29. Enter the billing provider in field 33. If you are individual provider you will enter your last name and then your first name. Enter your address. Enter the billing provider's NPI in field 33a. The taxonomy code is only required if you are using your NPI to relate to
more than 1 VT Medicaid provider number.
Vermont Medicaid Primary Claim Example
123456
Last Name, First Name
x x x
Last Name, First Name Street Address City, State, Zip Code
1234567890
11 99213 1 95.0 0 1 1234567890
95 00 401.9
x
010113 013113
This example shows all of the mandatory fields for a beneficiary who only has Vermont Medicaid.
• The VT Medicaid beneficiary is the insured; therefore, field 4 is not a required field.
• You do not need to complete the beneficiary address in field 5 and 7.
• You do not need a signature on each claim form nor is it required in field 31.
• The signature must be kept on file in your office.
Primary Insurance Claim Example
Field Locator 29, enter the amount paid by other health insurance coverage, including contractual allowance if applicable (exclude Medicare
payments). If this field is completed, field locators 11a, 11b and 11c must also be completed. Enter spend down, if applicable. Documentation must be attached if the services are not covered by the
primary insurer, or if the payment by the primary is
$3.00 or less.
123456
Last Name, First Name
x x x
Last Name, First Name Street Address City, State, Zip Code
1234567890
05 25 12 11 99213 1 95 00 1 1234567890
95 00 401.9
1234567890
75.00
X
Policy number MM DD YY Company name
Field C is a required field when Primary Insurance is applicable.
Enter the payment plus contractual allowance and enter the sum in field 29. Attach the explanation of benefits (EOB), if the services are not covered by the primary insurance. Include an explanation of the EOB remark when it was applied to the primary insurance deductible or if the
payment is $3.00 or less.
Medicare Claim Example
If you do not receive payment from DVHA within 30 days of the Medicare paid date, submit the claim to HPES
with a completed Medicare Attachment Summary Form.
If a service or item is denied by Medicare as non-
reimbursable but the service is reimbursable by Vermont Medicaid, submit a CMS 1500 claim for the non-
reimbursable service(completed to DVHA specifications) include a copy of the Medicare denial within twelve
months of the date of service to HPES.
123456
Last Name, First Name
x x x
Last Name, First Name Street Address City, State, Zip Code
1234567890
12 2 03 12 22 99213 1 27 00 1 1234567890
111 00 770.89
1234567890
25
12 03 12 22 31575 1 84 00 1 1234567890
When Medicare is primary, there is no need to complete any additional information/fields than what is
included on this example.
Last Name, First Name Last Name, first Name
X
4.93 19.71 3912341035230
15.21 60.86 3912341035230 80.57
12/20/12
The billing provider must indicate their last name and then their first name.
Complete field 1a if there is other insurance like UHC or AARP. Their payment would be entered in field 1c. If there is no other insurance other than Medicare, complete field 1b. Enter the Medicare paid date in field 2 and the Medicare payment in field 3. Complete 4a, b, c, d and e for each detail as shown.
INSTRUCTIONS FOR COMPLETING THE CMS 1500 MEDICARE ATTACHMENT SUMMARY FORM
Please complete and attach the Medicare Attachment Summary Form to the CMS 1500 Claim Form, this replaces the need to submit a copy of the Medicare EOB.
The Medicare Summary Attachment Form is designed to assist providers submitting Medicare deductible and/or co-insurance claims. Six lines are provided to correlate to the six claim lines/details contained on the CMS 1500 Claim Form. The Medicare Summary Attachment Form must be completed and attached to all CMS 1500 claims for Medicare deductible and/or co-insurance.
Please DO NOT staple or paper clip this form to your claims
Billing provider and Recipient information section must be completed as indicated on the claim
Other Insurance - Check yes or no. If you are checking yes also enter the
payment in the amount field. If there is no payment, please attach the other insurance EOB.
Medicare Paid Date – Enter Medicare EOMB date from the Medicare EOB. If you have more than one EOB for the same claim, enter the oldest Medicare EOMB Date.
Total Medicare Paid Amount - Enter the SUM of the Medicare paid amounts from the Medicare EOB for the details that apply to the crossover claim.
Medicare Deductible – Enter the DEDUCTIBLE amount for each applicable detail.
Medicare Co-Insurance – Enter the CO-INSURANCE amount for each applicable detail.
Medicare Paid Amount – Enter the Medicare Paid Amount for each applicable detail. If you have more than one payment for the same claim, combine the payments.
Medicare ICN – please enter the ICN for the applicable detail from the
Medicare EOB. If you have more than one EOB for the same claim, enter the ICN from the oldest Medicare EOB.
Mental Health Claims - Add the co-insurance amount and the
PR-122 line amount together; enter the sum in the Co-insurance field.
Medicare Part C – please add co-pay to the co-insurance amount; enter the sum in the Co-insurance field.
Please note: Medicare Part C - Add the co-pay to the co-insurance and enter the sum in field 4c.
CMS 1500 BILLING INSTRUCTIONS
All information on the CMS 1500 claim form should be typed or legibly printed. Only the 08/05 version of this form is accepted for processing. The field locators listed below are used by HP when processing Vermont Medicaid claims. The field locators designated by an asterisk (*) are mandatory; other field locators are required when applicable. The field locators not listed below are not used in the Vermont Medicaid program and do not need to be completed.
FIELD LOCATOR REQUIRED INFORMATION
1. CARRIER IDENTIFICATION Check the Medicaid box.
1a. INSURED’S ID NUMBER* Enter the Vermont Medicaid ID
number as shown on the beneficiary’s Member ID card.
2. PATIENT’S NAME* Enter the beneficiary’s last and first
name.
10. CONDITION RELATED TO* Check appropriate box to indicate:
a. If condition is related to employment
b. If condition is related to an auto accident
c. If condition is related to any other type of accident.
If yes is checked in any of these boxes, enter the accident date in field locator 14.
11. INSURED’S POLICY NUMBER If the beneficiary has other health insurance (excluding Medicare), enter the applicable policy number.
a. Enter the insured’s date of birth in MMDDYY format; check the appropriate box to indicate insured’s sex.
b. Enter the insured’s employer or school name.
c. Enter the name of the other health insurance carrier.
11d. IS THERE ANOTHER HEALTH BENEFIT PLAN* Check the appropriate box. If yes, complete fields 9 a-c. Health benefits provided under Green Mountain Care are not considered other insurance. Other insurance only pertains to a private health insurance carrier.
Detailed CMS 1500 instructions taken from the provider manual. Only the field locators with the * are mandatory fields. This example is subject to
change, see the Provider Manual located at http://www.vtmedicaid.com/Downloads/manuals.html
14. DATE OF CURRENT If your response indicates a ‘yes’ in field locators 10a, 10b or 10c, enter the date of the occurrence.
15. SAME OR SIMILAR ILLNESS Enter the therapy start date in MMDDYY format if billing physical, occupational or speech therapy.
17a. TAXONOMY/REFERRING PROVIDER Enter the referring provider’s taxonomy code when applicable.
17b. NPI/REFERRING PROVIDER* Enter the referring provider’s NPI.
Enter the prescribing NPI for
independent lab and DME suppliers.
19. LOCAL USE Use this field to explain unusual
services or circumstances and to indicate "page x of y" of a multiple page claim.
21. DIAGNOSIS CODE(S)* Enter the appropriate IDC-9-CM
diagnosis code that relates to the service rendered. You may use up to four diagnosis codes.
24a. DATE(S) OF SERVICE* Enter the date of each service provided. If the From and To dates are the same, the To date is not required.
24b. PLACE OF SERVICE* Enter the appropriate two digit place of service code.
24c. EMG Enter ‘1’ to indicate if the service
provided was the result of an
emergency. *This field is mandatory only if emergency services were provided.
24d. PROCEDURE CODE* Enter the appropriate procedure code
to explain the service rendered.
24e. DIAGNOSIS POINTER* Enter the appropriate diagnosis
‘pointer’ that relates to the service rendered (1 or 2 or 3 or 4) and corresponds to the diagnosis from field locator 21.
24f. CHARGES* Enter the usual and customary
charge for the service rendered.
24g. DAYS OR UNITS* Enter the number of days or units of service which were rendered.
24h. EPSDT/FAMILY PLAN Enter one of the following Vermont
Medicaid EPSDT and Family Planning indicators:
1-Both EPSDT and Family Planning 2-Neither EPSDT nor Family
Planning 3-EPSDT Only
4-Family Planning Only
24j. ATTENDING PROVIDER* Enter attending physician’s NPI.
Enter the billing provider NPI for independent labs and DME suppliers.
If Atypical, enter the 7-digit
Vermont Medicaid ID number in the shaded area.
26. PATIENT’S ACCOUNT NUMBER Enter the account number you have assigned to the beneficiary. HP can accept up to 12 digits; alpha, numeric, or alpha/numeric in this field. This information will print on the Remittance Advice summary for your accounting purposes.
28. TOTAL CHARGE* Add the charges from field locator
24f for each line and enter the total in this field.
29. AMOUNT PAID* Enter the amount paid by other
health insurance coverage, including contractual allowance if applicable (exclude Medicare payments). If this field is completed, field locators 11a, 11b and 11c must also be completed.
Enter spend down if applicable.
Documentation must be attached if the services are not covered by the primary, or if the payment by the primary is $3.00 or less.
31. SIGNATURE Enter the provider’s signature or
facsimile, or signature of the
provider’s authorized representative.
Enter the date of the signature.
33. BILLING PROVIDER* Enter the payee provider name and address (Individual provider format:
last name, first name)
33a. BILLING PROVIDER’S NPI* Enter the billing provider’s NPI.
33b. BILLING PROVIDER’S TAXONOMY Enter the billing provider’s
taxonomy code when applicable. If Atypical, enter the 7-digit Vermont Medicaid ID number in the shaded area.
Common Mistakes
• Alignment - (text entered on claim is offset from boxes on claim form)
• Mandatory fields are not completed
• Individual provider name (Field Locator 33) is not formatted correctly - Last Name, First
Name is the correct formatting
• Insured’s ID should not be the social security number - The insured’s ID is the Vermont
Medicaid ID Number
FAQ
Q. What is a diagnosis pointer?
A. The diagnosis pointer(s) go in field 24E and they relate back to the diagnoses indicated in field 21.
Q. Does the provider have to sign the claim form?
A. The provider does not have to sign the claim form.
Q. What is a taxonomy code?
A. The taxonomy indicate the specialty of the provider. You would have indicated this when you applied for your NPI.
Q. Where do we get the diagnosis codes?
A. You get the diagnosis codes from the ICD 9 diagnosis manual or go www.ICD9data.com
Q. What is a CPT code or HCPC?
A. The CPT code or HCPC is the code that describes the service you have rendered. You must use a CPT manual to research what codes to bill.
Q. Why are claims returned that have staples?
A. Staples cause issues with our optical character reader. Even if they are removed, the holes they create can cause it to jam.
Q. Where do we find CMS 1500 claim forms?
A. You can get CMS 1500 claims forms at an office supply store.
Resources
• Green Mountain Care Provider Manual
& Other Informational Resources
http://www.vtmedicaid.com/Downloads/manuals.html
• Forms
http://www.vtmedicaid.com/Downloads/forms.html
• Banner Page
http://www.vtmedicaid.com/Information/whatsnew.html
• Advisories
http://www.vtmedicaid.com/Downloads/bulletins.html
• Provider Electronic Solutions (PES) free billing software
http://www.vtmedicaid.com/Downloads/software.html
• Vermont Medicaid Portal
http://www.vtmedicaid.com/index.html
• CPT Code Book and HCPCS Manual
• ICD 9 Diagnosis Manual
• Please no staples
• No paper Clips
• No Writing on claim
• No Sticky notes
• No Black and White
• Please attachments under claim
• Do not highlight information on claim
Mailroom Information
• Document control: on an
average they sort, batch, scan and prepare 3,000 paper claims a day.
• Claims are batched into one of 10 claim types, depending on the type of claim or the place of service: Physician, Inpatient, Outpatient, Home Health,
Hospice, Nursing Home, Dental and Medicare crossovers.
• Optical Character Reader: when a claim goes through the
Optical Character Reader the system generates an ICN
number and gives you the date, batch number, and the region.
HP Enterprise Services
PO Box 777–PHYS CMS 1500 PO Box 888-Adjustments PO Box 1645-Refunds Williston, Vermont 05495
