completing CMS 1500 instruction – Field 1 – 13
Member Information (Fields 1-13)
Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).
Field Number : 1a
Field Description : Insured’s ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.
Field Number : 2
Field Description : Patient’s name
Data Type : Required
Instructions : Enter the patient’s last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.
Field Number : 3
Field Description : Patient’s birth date and gender
Data Type : Required
Instructions : Enter the patient’s birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.
Field Number : 4
Field Description : Insured’s name
Data Type : Required
Instructions : Enter the insured’s full last name, first name and middle initial. If the insured has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name.
Field Number : 5
Field Description : Patient’s address, city, state, zip code and telephone number
Data Type : Required
Instructions :Enter the patient’s mailing address and telephone number. On the first line, enter the street address (apartment number or Post Office Box number); the second line, the city and state; the third line, the ZIP code and phone number.
NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
Field Number : 6
Field Description : Patient’s relationship to the insured
Data Type : Required
Instructions : Check the appropriate box for the patient’s relationship to the insured when item 4 is completed. Remember that the patient’s relationship to the insured is not always “self”.
Field Number : 7
Field Description : Insured’s address, city, state, zip code and telephone number
Data Type : Required
Instructions : Enter the insured’s address (apartment/PO box number, street, city, state, zip code and telephone number with area code). When the address is the same as the patient’s enter the word “same”. Complete this item only when items 4 and 11 are completed.
NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
Field Number : 8
Field Description : Patient status
Data Type : Required
Instructions : Check the appropriate box for the patient’s marital status and whether employed or a student.
Field Number : 9
Field Description : Other insured’s name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the name (last name, first name, middle initial) of the person who is insured under other payer.
Field Number : 9a
Field Description : Other insured’s policy or group number
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s policy or group number or the insured’s identification number.
Field Number : 9b
Field Description : Other insured’s date of birth
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the eight-digit date of birth in MM/DD/CCYY format and enter an “X” to indicate the sex of the other insured. Only one box can be marked. If gender is unknown, leave blank.
Field Number : 9c
Field Description : Other insured’s employer’s name or school name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s employer’s name or school.
Field Number : 9d
Field Description : Other insured’s insurance plan name or program name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s insurance company or program name.
Field Number : 10a – c
Field Description : Is the patient’s condition related to:
• Employment?
• Auto accident?
• Other accident?
Data Type : Required
Instructions : Place an “X” in the box indicating whether or not the condition for which the patient is being treated is related to current or previous employment, an automobile accident or any other accident. Enter an “X” in either the YES or NO box for each question.
NOTE: The state postal code must be shown if “yes” is marked in 10b for “auto accident”. Any item marked yes indicates there may be other applicable insurance coverage that would be primary such as automobile liability insurance. Primary insurance information must then be shown in item 11.
Field Number : 10d
Field Description : Reserved for local use
Data Type : Not required
Instructions : Please leave blank.
Field Number : 11
Field Description : Insured’s policy group or FECA number
Data Type : Optional
Instructions : Enter the Insured’s policy or group number as it appears on the insured’s health care identification card.
Field Number : 11a
Field Description : Insured’s date of birth and sex
Data Type : Conditional
Instructions : Required if the patient is not the insured. Enter the insured’s eight-digit birth date in the MMDDCCYY format and sex if different from item 3.
Field Number : 11b
Field Description : Employer name or school name
Data Type : Conditional
Instructions : Enter the insured’s employer’s name, if applicable. If the insured is eligible by virtue of employment or covered under a policy as a student, enter the employer or school name.
Field Number : 11c
Field Description : Insurance plan name or program name
Data Type : Conditional
Instructions : Enter the insured’s insurance company or program name.
Field Number : 11d
Field Description : Is there another health benefit plan?
Data Type : Required
Instructions : Place an “X” in the box indicating whether there may be other insurance involved in the reimbursement of this claim.
Field Number : 12
Field Description : Patient’s or authorized person’s signature (Medicaid/other information release)
Data Type : Conditional
Instructions : The patient must sign and date the claim if authorizing the release of medical information. If “signature on file” is indicated, the provider must maintain a signed release form or CMS-1500 (formally HCFA 1500).
The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier, when the provider of service or supplier accepts assignment on the claim.
Field Number : 13
Field Description : Insured’s or authorized person’s signature
Data Type : Conditional
Instructions : The signature in this item authorizes payment of benefits to the physician or supplier. Signature on file, SOF, or the legal signature are acceptable. If there is no signature on file leave this item blank or enter “no signature on file”.
Member Information (Fields 1-13)
Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).
Field Number : 1a
Field Description : Insured’s ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.
Field Number : 2
Field Description : Patient’s name
Data Type : Required
Instructions : Enter the patient’s last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.
Field Number : 3
Field Description : Patient’s birth date and gender
Data Type : Required
Instructions : Enter the patient’s birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.
Field Number : 4
Field Description : Insured’s name
Data Type : Required
Instructions : Enter the insured’s full last name, first name and middle initial. If the insured has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name.
Field Number : 5
Field Description : Patient’s address, city, state, zip code and telephone number
Data Type : Required
Instructions :Enter the patient’s mailing address and telephone number. On the first line, enter the street address (apartment number or Post Office Box number); the second line, the city and state; the third line, the ZIP code and phone number.
NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
Field Number : 6
Field Description : Patient’s relationship to the insured
Data Type : Required
Instructions : Check the appropriate box for the patient’s relationship to the insured when item 4 is completed. Remember that the patient’s relationship to the insured is not always “self”.
Field Number : 7
Field Description : Insured’s address, city, state, zip code and telephone number
Data Type : Required
Instructions : Enter the insured’s address (apartment/PO box number, street, city, state, zip code and telephone number with area code). When the address is the same as the patient’s enter the word “same”. Complete this item only when items 4 and 11 are completed.
NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
Field Number : 8
Field Description : Patient status
Data Type : Required
Instructions : Check the appropriate box for the patient’s marital status and whether employed or a student.
Field Number : 9
Field Description : Other insured’s name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the name (last name, first name, middle initial) of the person who is insured under other payer.
Field Number : 9a
Field Description : Other insured’s policy or group number
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s policy or group number or the insured’s identification number.
Field Number : 9b
Field Description : Other insured’s date of birth
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the eight-digit date of birth in MM/DD/CCYY format and enter an “X” to indicate the sex of the other insured. Only one box can be marked. If gender is unknown, leave blank.
Field Number : 9c
Field Description : Other insured’s employer’s name or school name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s employer’s name or school.
Field Number : 9d
Field Description : Other insured’s insurance plan name or program name
Data Type : Conditional
Instructions : Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s insurance company or program name.
Field Number : 10a – c
Field Description : Is the patient’s condition related to:
• Employment?
• Auto accident?
• Other accident?
Data Type : Required
Instructions : Place an “X” in the box indicating whether or not the condition for which the patient is being treated is related to current or previous employment, an automobile accident or any other accident. Enter an “X” in either the YES or NO box for each question.
NOTE: The state postal code must be shown if “yes” is marked in 10b for “auto accident”. Any item marked yes indicates there may be other applicable insurance coverage that would be primary such as automobile liability insurance. Primary insurance information must then be shown in item 11.
Field Number : 10d
Field Description : Reserved for local use
Data Type : Not required
Instructions : Please leave blank.
Field Number : 11
Field Description : Insured’s policy group or FECA number
Data Type : Optional
Instructions : Enter the Insured’s policy or group number as it appears on the insured’s health care identification card.
Field Number : 11a
Field Description : Insured’s date of birth and sex
Data Type : Conditional
Instructions : Required if the patient is not the insured. Enter the insured’s eight-digit birth date in the MMDDCCYY format and sex if different from item 3.
Field Number : 11b
Field Description : Employer name or school name
Data Type : Conditional
Instructions : Enter the insured’s employer’s name, if applicable. If the insured is eligible by virtue of employment or covered under a policy as a student, enter the employer or school name.
Field Number : 11c
Field Description : Insurance plan name or program name
Data Type : Conditional
Instructions : Enter the insured’s insurance company or program name.
Field Number : 11d
Field Description : Is there another health benefit plan?
Data Type : Required
Instructions : Place an “X” in the box indicating whether there may be other insurance involved in the reimbursement of this claim.
Field Number : 12
Field Description : Patient’s or authorized person’s signature (Medicaid/other information release)
Data Type : Conditional
Instructions : The patient must sign and date the claim if authorizing the release of medical information. If “signature on file” is indicated, the provider must maintain a signed release form or CMS-1500 (formally HCFA 1500).
The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier, when the provider of service or supplier accepts assignment on the claim.
Field Number : 13
Field Description : Insured’s or authorized person’s signature
Data Type : Conditional
Instructions : The signature in this item authorizes payment of benefits to the physician or supplier. Signature on file, SOF, or the legal signature are acceptable. If there is no signature on file leave this item blank or enter “no signature on file”.