How to Fill Out CMS-1500 & UB-04 Forms: Step-by-Step Guide

How to Fill Out CMS-1500 & UB-04 Forms: Step-by-Step Medical Billing Guide

Overhead view of a medical billing desk with CMS-1500 and UB-04 forms, stethoscope, pen, and glasses

Summary

The CMS-1500 (Form 1500) is used by non-institutional providers (e.g., physicians, DME suppliers), while the UB-04 (Form CMS-1450) is the standard institutional claim form (hospitals, skilled nursing, etc.). This guide explains each form’s purpose, structure, and critical fields—especially the two-digit qualifiers in fields 17a, 24I, 32b, and 33b on the CMS-1500—and provides a high-level walkthrough of UB-04 locators 43–81.

CMS-1500 (Form 1500) Overview

  • Purpose: Billing professional and supplier services to Medicare and commercial payers on paper when electronic submission (837P) isn’t used CMS.
  • Maintained by: National Uniform Claim Committee (NUCC) with OMB approval; current version 02/12 (effective 01/06/14) CMS.
  • Capacity: Accommodates patient/provider demographics, up to six service lines (Box 24), and up to four modifiers per line CMS.

Key Form Sections

  1. Boxes 1–13: Patient and insured information.
  2. Box 17a/17b: Referring, ordering, or supervising provider NPI (17b) and other ID (17a) with qualifier.
  3. Box 21: Diagnosis code pointers (A–L) linked to Box 24 lines.
  4. Box 23: Prior authorization number and resubmission code (6=Corrected, 7=Replacement, 8=Void) support.unifiedpractice.com.
  5. Box 24a–g: Service dates (24a), place of service (24b), emergency (24c), procedure codes/modifiers (24d), diagnosis pointers (24e), charges (24f), units (24g) support.unifiedpractice.comCMS.
  6. Boxes 32–33: Billing provider NPI (32a/33a) and other ID (32b/33b) with qualifier.
  7. Boxes 31, 34–33b: Signature, provider address, and certification.

Step-by-Step Guide to Completing the CMS-1500

1. Patient & Insured Information (Boxes 1–13)

  • Enter patient’s name, birth date, address, insured ID, and relationship to insured.

2. Provider Identifiers with Two-Digit Qualifiers

Box 17a (“Other ID#”)

  • Enter non-NPI ID of referring/ordering/supervising provider preceded by a two-digit qualifier (e.g., 0B=State License, 1G=UPIN, ZZ=Taxonomy) Sharp Health Plan.

Box 17b (NPI)

  • Enter the NPI of the referring/ordering/supervising provider.

3. Service Lines (Box 24)

  • 24a: “From” and “To” dates of service (MM/DD/YY – MM/DD/YY).
  • 24b: Place of service code (two-digit POS codes; e.g., 11=Office, 22=On-campus outpatient hospital) National Uniform Claim Committee.
  • 24c: Emergency indicator (“Y” if emergency).
  • 24d: CPT/HCPCS code + up to four two-digit modifiers (no narrative) CMS.
  • 24e: Diagnosis pointer (A–L on v02/12; 1–4 on v08/05).
  • 24f: Line‐item charge (right-justified, no commas).
  • 24g: Units (days or CPT units; enter “1” if single service).

4. Billing Provider (Boxes 32–33)

  • 32a/33a: Billing provider/service facility NPI.
  • 32b/33b: Other ID# with qualifier (same qualifier set as Box 17a) Sharp Health Plan.

Two-Digit Qualifiers (Fields 17a, 24I, 32b, 33b)

The following qualifiers identify the type of “Other ID” on paper CMS-1500 claims:

QualifierDescriptionSource
0BState License NumberAAFP
1BBlue Shield provider numberAAFP
1CMedicare provider numberAAFP
1DMedicaid provider numberAAFP
1GProvider UPINAAFP
1HCHAMPUS identification numberAAFP
EIEmployer’s identification numberAAFP
G2Provider commercial numberAAFP
LULocation numberAAFP
N5Provider plan network identification numberAAFP
SYSocial Security number (not for Medicare claims)AAFP
X5State industrial accident provider numberAAFP
ZZProvider taxonomy (or narrative if unspecified)AAFP
N4National Drug Code (NDC)FindACode
VPVendor product number (HIBCC standard)AAFP
OZProduct number (GTIN – HCUP/GS1 standard)AAFP
CTRContract rateAAFP

Note: Field “24I” on 02/12 is a shaded supplemental field rarely used; when used, qualifiers follow the same list.

UB-04 (Form CMS-1450) Overview

  • Also known as: CMS-1450 – Uniform Bill (UB-04).
  • Use by: Institutional providers (hospitals, home health, SNFs) for inpatient/outpatient facility claims CMS.
  • Maintained by: National Uniform Billing Committee (NUBC); instructions in CMS Claims Processing Manual, Chapter 25 CMS.
  • Form Locators: 1–81 (Key locators 43–65 for charges/details; 66–81 for provider IDs, diagnosis/procedure qualifiers) CMS.

Key UB-04 Locators

  • Locators 1–4: Provider, patient control number, insurer.
  • Locators 42–45: Revenue codes, HCPCS/CPT codes, charges.
  • Locator 66: Diagnosis and Procedure Code Qualifier (e.g., “9” for ICD-9, “0” for ICD-10 after 10/01/15) healthplan.geisinger.org.
  • Locator 67–74: Principal/Other diagnosis & procedure codes with dates.
  • Locators 76–79: Attending, operating, other provider names & IDs (NPI and qualifier, e.g., 1G for UPIN) healthplan.geisinger.org.
  • Locators 80–81: Remarks and billing provider contact.

Comparing CMS-1500 vs. UB-04

AspectCMS-1500 (1500)UB-04 (1450)
Provider TypeNon-institutional (MDs, DME)Institutional (hospitals, facilities)
Maintained byNUCCNUBC
Form Fields33 boxes81 locators
Use of QualifiersTwo-digit qualifiers in 17a, 24I, 32b, 33bQualifier in Loc 66 & in 76–79
Electronic EquivalentX12 837PX12 837I

Conclusion

This guide equips you to complete both the CMS-1500 and UB-04 paper claim forms accurately, with special attention to the two-digit qualifiers that identify non-NPI identifiers. Always verify with your payer for any additional supplemental requirements, and refer to the latest NUCC and NUBC instruction manuals on www.cms.gov for updates.
read more UB-04 Forms

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