Get Cms-1500 Claims Submission Toolkit

Professional Claims If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

This box contains the Billing Provider's name, address, and phone number. This information lets the Insurance company know where to direct payment. Note that the Billing Provider can be an individual or a group/organization.

Box 32b is used to indicate the non-NPI identification number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier followed by the ID number. The following qualifiers can be used: 0B - State License Number.

Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim.

In the framework of the CMS1500 form, the ZZ qualifier in box 33b corresponds to the provider's taxonomy code. This particular code is a unique identifier for the type of health care provider, be it a doctor, nurse, physical therapist, or another professional in the healthcare sector.

Box 33B: By default, this box will remain blank; however, if a particular payer wants to see a separate provider ID number in that box, you can add it, by the provider, for that particular payer.

Expert-Verified Answer. The CMS-1500 form requires patient information, provider information, date of service, procedure codes, diagnosis codes, charges, insurance information, and signature. The CMS-1500 form is a standard document used by healthcare providers to bill for services provided to patients.

The HCFA 1500 claim form, also known as CMS-1500, enables medical physicians to submit health insurance claims for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare.