CMS-1500 Claim Form Instructions Health Insurance Claim Form

The following Iowa Medicaid provider types bill for services on the CMS-1500 claim form: Ambulance, Ambulatory Surgical Centers, Area Education Agencies, Audiologists, Birthing Centers, Certified Registered Nurse Anesthetists, Chiropractors, Clinics, Community Mental Health Clinics, Family Planning Clinics, Federally Qualifying Health Centers, Hearing Aid Dealers, Independently Practicing Physical Therapists, Lead Investigation Agencies, Maternal Health Centers, Medical Equipment and Supply Dealers, Nurse Midwives, Opticians, Optometrists, Orthopedic Shoe Dealers, Physicians, Rural Health Clinics and Screening Centers.

The billing instructions below contain information that will aid in the completion of the CMS-1500 claim form. The table follows the claim form by field number and name, giving a brief description of the information to be entered, and whether providing information in that field is required, optional or conditional of the individual recipient’s situation.

For electronic media claim (EMC) submitters, refer also to your EMC specifications for claim completion instructions.

If you have any questions about this form or instructions, please contact IME Provider Services at 800-338-7909, or if within the local Des Moines area call 515-256-4609. 

Field No.	Field Name/ Description	Requirements	Instructions
1	Check One	REQUIRED	Check the applicable program.
1a.	Insured’s ID Number	REQUIRED	Enter the Medicaid member’s Medicaid number found on the Medical Assistance Eligibility Card. The Medicaid Member is defined as the recipient of services who has Iowa Medicaid coverage. The Medicaid number consists of seven digits followed by a letter, i.e., 1234567A. Verify eligibility by visiting the web portal or by calling the Eligibility Verification System (ELVS) at 800-338-7752 or 515-323- 9639, local in the Des Moines area. To establish a web portal account, call 800-967-7902.
2	Patient’s Name	REQUIRED	Enter the last name, first name, and middle initial of the Medicaid member.

3	Patient’s Birth Date	OPTIONAL	Enter the birth date and sex of the member.
4	Insured’s Name	OPTIONAL	For Medicaid purposes, this will always be the same as the patient. The insured: For Iowa Medicaid purposes, the member is the insured. If the member is covered through other insurance, the policy-holder is the “other insured”.
5	Patient’s Address	OPTIONAL	Enter the address and phone number of the patient, if available.
6	Patient Relationship to Insured	OPTIONAL	For Medicaid purposes, the insured will always be the same as the patient.
7	Insured’s Address
8	Patient Status	SITUATIONAL	REQUIRED, if known.  Check boxes corresponding to the patient’s current marital and occupational status.
9	Other Insured’s Name	SITUATIONAL	REQUIRED if the Medicaid member is covered under other additional insurance enter the name of the policy holder of that insurance, as well as the policy or group number, the employer or school name under which coverage is offered and the name of the plan or program. If 11d is “Yes”, these boxes must be completed.
9a-d.	Other Insured’s Name, etc.	SITUATIONAL	REQUIRED if the Medicaid member is covered under other additional insurance enter the name of the policy holder of that insurance, as well as the policy or group number, the employer or school name under which coverage is offered and the name of the plan or program. Note: If 11d is “Yes”, these boxes must be completed.
10	Is Patient’s Condition Related To:

10a.	Employment?	SITUATIONAL	REQUIRED if known.  Check the appropriate box to indicate whether or not treatment billed on this claim is for a condition that is somehow work or accident related. If the patient’s condition is related to employment or an accident, and other insurance has denied payment, complete 11d, marking the “YES” and “NO” boxes.
10b.	Auto Accident?
10c.	Other Accident?
10d.	Reserved for Local Use	OPTIONAL	No entry required.
11a-c.	Insured’s Policy Group or FECA Number and Other Information	OPTIONAL	For Medicaid purposes, the insured will always be the same as the patient.
11d.	Is There Another Health Benefit Plan?	REQUIRED	REQUIRED if the Medicaid member has other insurance, check “YES” and enter payment amount in field 29.  If “YES”, then boxes 9a-9d must be completed. If there is not other insurance check “NO”. If you have received a denial of payment from another insurance, check both “YES” and “NO” to indicate that there is other insurance, but that the benefits were denied. Proof of denials must be included in the patient record. Request this information from the member. You may also determine if other insurance exists by visiting the web portal or by calling the Eligibility Verification System (ELVS) at 800- 338-7752 or 515-323-9639, local in the Des Moines area. To establish a web portal account, call 800-967-7902. Note:  Auditing will be performed on a random basis to ensure correct billing.
12	Patient’s or authorized person’s	OPTIONAL	No entry required.

	signature
13	Insured or authorized person’s signature	OPTIONAL	No entry required.
14	Date of current illness, injury or pregnancy	SITUATIONAL	If treatment is related to an accident enter the date of accident or the onset of treatment. Entry should be made in MM/DD/YY format. For pregnancy, use the date of the last menstrual period (LMP).  This field is not required for preventative care.
15	If the patient has had same or similar illness…	SITUATIONAL	REQUIRED for Chiropractors. Chiropractors must enter the date of the most current x-ray. Entry should be made in MM/DD/YY format.
16	Dates patient unable to work….	OPTIONAL	No entry required.
17	Name of referring provider or other source	OPTIONAL	No entry required.
17a.	Untitled	LEAVE BLANK	This field must be left blank.
17b.	NPI	SITUATIONAL	REQUIRED if: The patient is a MediPASS member and the MediPASS provider authorized service, enter the 10-digit NPI of the referring MediPASS provider. If this claim is for consultation, independent lab, or DME, enter the NPI of the referring or prescribing provider. If the patient is on lock-in and the lock-in provider authorized service, enter the NPI of the lock-in Primary Care Provider (PCP).

18	Hospitalization Dates Related to Current Services	OPTIONAL	No entry required.
19	Reserved for Local Use	OPTIONAL	No entry required. Note:  Pregnancy is now indicated with a pregnancy diagnosis code in field 21. If unable to enter a diagnosis code to indicate pregnancy in 21, enter “Y-pregnant” in this field.
20	Outside lab	OPTIONAL	No entry required.
21	Diagnosis or nature of illness or injury	REQUIRED	Indicate the applicable ICD-9-CM diagnosis codes in order of importance (1-primary; 2- secondary; 3-tertiary; 4 – quaternary) to a maximum of four diagnoses. If the patient is pregnant, one of the diagnosis codes must indicate pregnancy. The pregnancy diagnosis codes are as follows: 640 through 648; 670 through 677; V22; V23. DO NOT enter descriptions.
22	Medicaid resubmission	OPTIONAL	No entry required.
23	Prior authorization number	SITUATIONAL	REQUIRED if there is a prior authorization, enter the prior authorization number. Obtain the prior authorization number from the prior authorization form.
24A. top shaded portion	Date(s) of Service/NDC	SITUATIONAL	REQUIRED for provider-administered drugs. Enter qualifier “N4” followed by the NDC for the drug referenced in 24d (HCPCs). No spaces or symbols should be used in reporting this information.
24A. lower portion	Date(s) of Service	REQUIRED	Enter month, day and year under both the From and To categories for each procedure, service, or supply.
24b.	Place of Service	REQUIRED	Using the chart below, enter the number corresponding to the place service was provide. DO NOT use alphabetic characters.

			11 – Office 12 – Home 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency room – hospital 24 – Ambulatory surgical center 25 – Birthing center 26 – Military treatment facility 31 – Skilled nursing… 32 – Nursing facility 33 – Custodial care facility 34 – Hospice 41 – Ambulance – land 42 – Ambulance – air or water 51 – Inpatient psychiatric facility 52 – Psychiatric facility – partial hospitalization 53 – Community mental health center 54 – Intermediate care facility/mentally retarded 55 – Residential substance abuse treatment facility 56 – Psychiatric residential treatment center 61 – Comprehensive inpatient rehabilitation facility 62 – Comprehensive outpatient rehabilitation facility 65 – End-stage renal disease treatment 71 – State or local public health clinic 81 – Independent laboratory 99 – Other unlisted facility
24c.	EMG	OPTIONAL	No entry required.
24d.	Procedures, services, or supplies	REQUIRED	Enter the codes for each of the dates of service. DO NOT list services for which no fees were charged. DO NOT enter the description.

			Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) or valid Current Procedural Terminology (CPT). When applicable, show HCPCS code modifiers with the HCPCS code.
24e. 24f.	Diagnosis pointer $ Charges	REQUIRED REQUIRED	Indicate the corresponding diagnosis code from field 21 by entering the number of its position, i.e., 3. DO NOT enter the actual diagnosis code in this field, doing so will cause the claim to deny. Note: There is a maximum of four diagnosis codes per claim.
			Enter the usual and customary charge for each line item billed. The charge must include both dollars and cents.
24g.	Days or Units	REQUIRED	Enter the number of times this procedure was performed or number of supply items dispensed. If the procedure code specifies the number of units, then enter “1.” When billing general anesthesia, the units of service must reflect the total minutes of general anesthesia.
24h.	EPSDT/ Family Plan	SITUATIONAL	REQUIRED if services are a result of an EPSDT Care for Kids screen or are for family planning services. Enter “F” if the service on this claim line is for family planning. Enter “E” if the services on this claim line are the result of an EPSDT Care for Kids screening.
24i.	ID. Qual.	LEAVE BLANK	This field must be left blank.
24J. top	Rendering Provider ID. #	LEAVE BLANK	This field must be left blank.

shaded portion
24J. Bottom portion	NPI	REQUIRED	Enter the NPI of the provider rendering the service.
25	Federal Tax I.D. Number	OPTIONAL	No entry required.
26	Patient’s Account No.	OPTIONAL	Enter the patient account number assigned to the patient by the provider of service. This field is limited to 10 alpha/numeric characters.
27	Accept Assignment?	OPTIONAL	No entry required.
28	Total Charge	REQUIRED	Enter the total of the line item charges on the LAST page of the claim. If more than one claim form is used to bill services performed, only the last page of the claim should give the claim Total Charge. The pages prior to the last page should have “continued” or “page 1 of     ” in Box 28.
29	Amount Paid	SITUATIONAL	REQUIRED if the member has other insurance and the insurance has made a payment on the claim.  Enter only the amount paid by other insurance. Member co-payments, Medicare payments or previous Medicaid payments are not listed on this claim. Do not submit this claim until you receive a payment or denial from the other carrier. Proof of denials must be included in the patient record. If more than once claim form is used to bill services performed and a prior payment was made, the third-party payment should be entered on each page of the claim in Box 29.
30	Balance due	REQUIRED	Enter the amount of total charges less the amount entered in field 29.

			If more than one claim form is used to bill services performed, only the last page of the claim should give the claim Balance Due. The pages prior to the last page should have “continued” or “page 1 of     ” in Box 30.
31	Signature of Physician or Supplier	REQUIRED	Enter the signature of either the physician or authorized representative and the original filing date. If the signature is computer-generated block letters, the signature must be initialed. A signature stamp may be used. The signatory must be someone who can legally attest to the service provided and can bind the organization to the declarations on the back of this form.
32	Service Facility Location Information	OPTIONAL	Enter the complete address of the treating/rendering provider.
32a.	NPI	OPTIONAL	Enter the NPI of the facility where service(s) were rendered.
32b.	Untitled	LEAVE BLANK	This field must be left blank.
33	Billing Provider Info & Phone #	REQUIRED	Enter the name and complete address of the billing provider. Note: The address must contain the zip code associated with the billing provider’s NPI. The zip code must match the zip code confirmed during NPI verification.
33a.	NPI	REQUIRED	Enter the NPI of the billing provider.
33b.	Untitled	REQUIRED	Enter the taxonomy code associated with the billing provider’s NPI. A “ZZ” qualifier must precede the taxonomy code. Note:

The taxonomy code must match the taxonomy code confirmed during NPI verification.