How to Fill Out CMS-1500 & UB-04 Forms: Step-by-Step Medical Billing Guide
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
- Boxes 1–13: Patient and insured information.
- Box 17a/17b: Referring, ordering, or supervising provider NPI (17b) and other ID (17a) with qualifier.
- Box 21: Diagnosis code pointers (A–L) linked to Box 24 lines.
- Box 23: Prior authorization number and resubmission code (6=Corrected, 7=Replacement, 8=Void) support.unifiedpractice.com.
- 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.
- Boxes 32–33: Billing provider NPI (32a/33a) and other ID (32b/33b) with qualifier.
- 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:
| Qualifier | Description | Source |
|---|---|---|
| 0B | State License Number | AAFP |
| 1B | Blue Shield provider number | AAFP |
| 1C | Medicare provider number | AAFP |
| 1D | Medicaid provider number | AAFP |
| 1G | Provider UPIN | AAFP |
| 1H | CHAMPUS identification number | AAFP |
| EI | Employer’s identification number | AAFP |
| G2 | Provider commercial number | AAFP |
| LU | Location number | AAFP |
| N5 | Provider plan network identification number | AAFP |
| SY | Social Security number (not for Medicare claims) | AAFP |
| X5 | State industrial accident provider number | AAFP |
| ZZ | Provider taxonomy (or narrative if unspecified) | AAFP |
| N4 | National Drug Code (NDC) | FindACode |
| VP | Vendor product number (HIBCC standard) | AAFP |
| OZ | Product number (GTIN – HCUP/GS1 standard) | AAFP |
| CTR | Contract rate | AAFP |
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
| Aspect | CMS-1500 (1500) | UB-04 (1450) |
|---|---|---|
| Provider Type | Non-institutional (MDs, DME) | Institutional (hospitals, facilities) |
| Maintained by | NUCC | NUBC |
| Form Fields | 33 boxes | 81 locators |
| Use of Qualifiers | Two-digit qualifiers in 17a, 24I, 32b, 33b | Qualifier in Loc 66 & in 76–79 |
| Electronic Equivalent | X12 837P | X12 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.
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