Last Updated: October 26, 2023

Disclaimer: This comprehensive guide provides detailed instructions for completing the Form CMS-1500 (02/12), OMB No. 0938-1197, specifically for professional claims submitted to Nebraska Medicaid. Please note that these instructions are tailored to Nebraska Medicaid policies and may not apply to other state Medicaid programs, commercial payers, or Medicare. Always refer to the specific guidelines of the payer you are billing.

This post is enhanced with suggestions for including clear, high-resolution screenshots or a downloadable PDF of the CMS 1500 form, with each numbered field highlighted, to further aid in the completion process.

Understanding the CMS 1500 Claim Form for Nebraska Medicaid

Claim Form Completion Instructions: The numbers listed below correspond to the numbers of the fields on the form. Completion of fields identified with an asterisk (*) is mandatory for claim acceptance. Information in fields without an asterisk is required for some aspect of claims processing/resolution. Fields that are not listed are not needed for Nebraska Medicaid claims.

Patient and Insured Information

*1a. INSURED’S I.D. NUMBER: Enter the Medicaid client’s complete eleven-digit identification number (Example: 123456789-01). When billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child, enter the Medicaid number of the unborn child (see 471 NAC 1-002.02K).

*2. PATIENT’S NAME: Enter the full name (last name, first name, middle initial) of the person that received services.

*3. PATIENT’S BIRTHDATE AND SEX: Enter the month, day, and year of birth of the person that received the services. Check the appropriate box (M or F).

4. INSURED’S NAME: Complete only when billing for pregnancy-related services provided to the ineligible mother of an eligible unborn child. Enter the Medicaid client’s name as it appears on the Nebraska Medicaid Card. This is the name of the person (the unborn child) whose number appears in Field 1a.

Understanding Third-Party Resources and Coordination of Benefits (Fields 9-14)

9. – 14. These fields address third-party resources (TPR) other than Medicaid or Medicare. If there is no known insurance coverage, leave these fields blank. If the client has insurance coverage other than Medicaid or Medicare, you must complete fields 9-11 and 14. Nebraska Medicaid requires all third-party resources to be exhausted before Medicaid payment may be issued.

Common Scenarios for Coordination of Benefits:

• Primary Commercial Insurance: If the patient has private health insurance, bill that insurer first.
• Medicare Secondary Payer: If Medicare is the primary payer, ensure Medicare processing is complete before billing Medicaid.
• Liability Insurance: Claims related to accidents (e.g., auto, worker’s compensation) must first be submitted to the responsible liability carrier.

Required Documentation: A copy of the remittance advice (RA), explanation of benefits (EOB), denial letter, or other official documentation from the primary payer is required and must be attached to the claim to demonstrate the exhaustion of other coverage. Failure to attach appropriate documentation can lead to claim denials. For further guidance on Nebraska Medicaid policies for coordination of benefits, refer to official state resources.

Provider and Service Information

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE: Enter the full name of the referring/prescribing physician.

17a. OTHER ID#: Leave qualifier field blank. Enter the license number of the referring physician in the shaded area of the large box in 17a. License number listings are available from the Medicaid Division. License numbers may also be accessed on the HHS web site: www.hhs.state.ne.us/med/medindex.htm. Click on “Pharmacy Program.”

NPI Requirements for Referring and Billing Providers (Fields 17b & 33a) in Nebraska Medicaid

17b. NPI #: While historically marked “Optional,” for HIPAA-covered entities, the National Provider Identifier (NPI) is generally a mandatory identifier for professional claims. Enter the NPI number of the referring provider, ordering provider, or other source. For specific Nebraska Medicaid guidelines regarding when an NPI is required for referring providers, always consult the latest Nebraska Medicaid provider manuals or the official CMS NPI information.

How to Fill Box 21: Entering ICD-10-CM Diagnosis Codes on CMS 1500

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY: The services on this claim form must be directly related to the diagnosis entered in this field. Enter the appropriate International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) diagnosis codes.

Critical Update: ICD-10-CM Coding Guidelines: Effective October 1, 2015, ICD-9-CM was replaced by ICD-10-CM. All claims must use ICD-10-CM codes.

• The COMPLETE ICD-10-CM diagnosis code is required. ICD-10-CM codes are alphanumeric and can be 3 to 7 characters long.
• Emphasize specificity: Always use the most specific code available, including laterality (e.g., right, left, bilateral) where applicable.
• Character Count: Ensure the code has the correct number of characters as defined by the official ICD-10-CM coding guidelines, which can be found on the CMS website.
• If there is more than one diagnosis, list the primary diagnosis first, followed by secondary diagnoses.

Additional Claim Details

22. MEDICAID RESUBMISSION: Leave blank. For regulations regarding resubmittal or adjustment requests, see 471 NAC 3-000 and 471-000-99. For detailed guidance, refer to Nebraska Medicaid’s policy on claim adjustments and resubmissions.

23 PRIOR AUTHORIZATION NUMBER: If the service requires prior authorization, enter the prior authorization number in this field. This number is mandatory to receive payment for any service or supply that requires prior authorization. For example, prior authorization requirements for hearing aid services are contained in 471 NAC 8-004.01. If the service does not require prior authorization, leave this field blank.

*24. SERVICE LINES: The six service lines in section 24 have been divided horizontally to accommodate the submission of supplemental information to support the billed service. The top shaded area of each of the six service lines is the designated location for reporting supplemental information. It is crucial to understand that this is not intended to allow the billing of 12 service lines; only six unique line items can be entered in Field 24. Do not print more than one line of information on each claim line. DO NOT LIST services for which there is no charge.

*24A. DATE(S) OF SERVICE: In the unshaded area, enter the 8-digit numeric date of service rendered (MMDDYYYY). Each procedure code/service billed requires a date. Each service must be listed on a separate line. The “From” date of service must be completed. The “To” date of service may be left blank if the service occurred on a single day.

*24B. PLACE OF SERVICE: In the unshaded area, enter the appropriate place of service code, e.g., 11 (Office). National place of service codes are defined by the Centers for Medicare and Medicaid Services (CMS) and published on the CMS web site.

*24D. PROCEDURES, SERVICES, OR SUPPLIES: In the unshaded area, enter the appropriate HCPCS procedure code and, if required, up to four procedure code modifiers. HCPCS procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule. When using miscellaneous and not otherwise classified (NOC) procedure codes, a complete description of the service is required. This description should be entered in the shaded area between 24D through 24H, provided as an 8 ½ x 11 attachment to the paper claim, or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims. For detailed information on HCPCS modifiers and their proper application, refer to relevant coding resources.

24E. DIAGNOSIS POINTER: In the unshaded area, enter the diagnosis code reference number as shown in Field 21 (1-4), linking the service line to the appropriate diagnosis code.

*24F. $ CHARGES: Enter the lab invoice cost for hearing aids and hearing aid repairs. Enter the fee schedule maximum allowable fee for dispensing fees. For other procedures, enter your customary charge. Do not list one charge for several procedure codes.

*24G. DAYS OR UNITS: Enter the number of services being claimed. If the procedure code description includes specific time or quantity increments, each increment should be billed as one unit of service. NOTE: Batteries are billed per battery, not per package of batteries. Nebraska Medicaid allows a maximum of 16 batteries per aid dispensed on a date of service.

*25. FEDERAL TAX I.D. NUMBER: Leave blank for Nebraska Medicaid claims, as per current guidelines.

26. PATIENT’S ACCOUNT NO.: Optional. Any patient account information (numeric or alpha) may be entered in this field to enhance patient identification. This information will appear on the Medicaid Remittance Advice.

*28. TOTAL CHARGE: Enter the total of all charges from Field 24, Column F. If more than one claim form is used to bill for services provided, EACH claim form must be submitted with its line items totaled. DO NOT carry charges forward to another claim form.

*29. AMOUNT PAID: Enter any payments made, due, or obligated from other sources for services listed on this claim. Other sources may include health insurance, liability insurance, or excess income. A copy of the Medicare or insurance remittance advice, explanation of benefits, denial, or other supporting documentation must be attached. DO NOT enter previous Medicaid payments, copayments, or the difference between the provider’s billed charge and the Medicaid allowable (provider “write-off” amount) in this field.

*30. BALANCE DUE: Enter the balance due. This amount is determined by subtracting the amount paid in Field 29 from the total charge in Field 28.

*31. SIGNATURE OF PHYSICIAN OR SUPPLIER: The provider or authorized representative must SIGN and DATE the claim form. A signature stamp, computer-generated, or typewritten signature will be accepted. The signature date must be on or after the date(s) of service listed on the form.

*33. BILLING PROVIDER INFO & PHONE # ( ): Enter the provider’s full name, complete address, zip code, and phone number.

33a. NPI #: While historically marked “Optional,” for HIPAA-covered entities, the National Provider Identifier (NPI) is generally a mandatory identifier. Enter the NPI number of the billing provider. For specific guidance on NPI requirements for billing providers in Nebraska Medicaid, consult official state resources.

33b. OTHER ID #: Enter the eleven-digit Nebraska Medicaid provider number as assigned by Nebraska Medicaid (example: 123456789-12). All payments are made to the name and address listed on the Medicaid provider agreement for this provider number.

Claim Attachments and Electronic Submission Considerations

Claim Attachments: For hearing aids and miscellaneous services, a copy of the purchase invoice must be attached to the paper claims or sent with the Electronic Claim Attachment Control Number Form (MC-2) for electronic claims.

Common Errors and How to Avoid Them on CMS 1500 for Nebraska Medicaid

To minimize claim denials and ensure timely reimbursement, be aware of these frequent mistakes:

• Incorrect ICD-10-CM Codes: Ensure codes are complete, specific, and reflect laterality. Using outdated ICD-9-CM codes will lead to immediate denial. Always refer to the latest ICD-10-CM Official Guidelines for Coding and Reporting.
• Missing or Incorrect NPI: Verify NPIs for both referring and billing providers are accurate and included where mandatory.
• Incomplete Patient Demographics: Double-check patient name, date of birth, sex, and Medicaid ID for accuracy.
• Unlinked Diagnosis to Service: Every service line in Field 24 must correctly point to a diagnosis in Field 21 via the diagnosis pointer (24E).
• Prior Authorization Issues: Services requiring prior authorization will be denied if the authorization number is missing or expired. Confirm authorization status before submission.
• Coordination of Benefits (COB) Failures: Failing to bill the primary payer first or not attaching appropriate EOBs/RAs will result in denials.

Paper vs. Electronic Claims: Key Differences and Considerations for Nebraska Medicaid

While this guide focuses on the paper CMS 1500 form, much of the information translates directly to electronic claim submission (EDI). Electronic claims utilize an 837 Professional transaction set, which mirrors the data elements found on the CMS 1500 form.

• Efficiency: EDI claims typically process faster and have lower error rates due to automated validation.
• Attachments: For electronic claims, physical attachments (like invoices) are usually replaced by submitting an Electronic Claim Attachment Control Number Form (MC-2) with the necessary documentation, or through secure electronic portals.
• Software Requirements: Electronic submission requires compatible billing software that can generate the 837P transaction.

Providers should understand that while the submission method differs, the fundamental data requirements and Nebraska Medicaid policies for claim accuracy remain the same. For specific guidance on Nebraska Medicaid electronic claim submission, consult the official EDI provider manuals.