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Commercial

Insurance

Block

BCBS

Medicare

x - other for ind/family plan


x - group plan

x - other for ind/family plan


x - group plan

Enter an X in the Medicare


box.

ID #

BCBS ID number

Enter the Medicare


identification number.

2
3

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

4
5

Policy Holder name LAST,


FIRST, MI
Pt's address & phone #

Policy Holder name LAST,


FIRST, MI
Pt's address & phone #

Leave Blank.
Pt's address & phone #

X in box to indicate patient's


relationship

X in box to indicate patient's


relationship

Leave Blank.

7
8

Policyholder's address
Leave blank

Policyholder's address
LEAVE BLANK

Leave Blank.
Leave Blank.

leave blank if no secondary


insurance
Leave blank.

Leave Blank.
Leave Blank.

Enter an X in the appropriate


box to indicate whether the
patient's condition is related
to employment, an auto
accident, and/or another
axccident.

Enter an X in the no boxes.

1
1a

leave blank if no secondary


9, 9a, 9d insurance
9b-9c
leave blank

10a-c

Enter X in appropriate box for


Workers Comp or accident

10d

leave blank

Leave blank.

Leave Blank.

11
11a

policyholder's group #
Policyholder's DOB

Enter non whoich indicates


Enter the policyholders BCBS the provider has made a
group number if the patient is good-faith effort to determine
covered by a group health
whether Medicare is the
plan.
primary or secondary payer.
Policyholder's DOB
Leave Blank.

11b

leave blank

Leave blank.

Leave Blank.

11c

Health Insurance Plan

Enter the name of the


policyholders BCBS health
insurance plan.

Leave Blank.

11d
12

X in the NO box if no other


coverage
SIGNATURE ON FILE

X in the NO box if no other


coverage
SIGNATURE ON FILE

Leave Blank.
SIGNATURE ON FILE

13

leave blank

LEAVE BLANK

Leave Blank.

14

enter the date as mm dd yyyy enter the date as mm dd yyyy enter the date as mm dd yyyy
to indicate when patient first
to indicate when patient first to indicate when patient first
expierenced symtoms
expierenced symtoms
expierenced symtoms

15

Enter the date asMM DD YYYY


to indicate that a prior episode
of the same illness began.
Leave blank

Leave Blank.

Enter date as MM DD YYYY to


indicate the period of time the
patient was unable to workin
his or her current occupation
Leave blank.

Enter date as MM DD YYYY to


indicate the period of time the
patient was unable to workin
his or her current occupation

17
17a

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave Blank

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave blank.

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave Blank.

17b

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

18
19

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave blank.

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave blank.

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave Blank.

20

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an outside
laboratory.

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an
outside laboratory.

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an
outside laboratory.

21

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or medically
managed during the
encounter.

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or
medically managed during the
encounter.

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or
medically managed during the
encounter.

16

22

Leave blank. This reserved for Leave blank. This reserved for Leave blank. This reserved for
resubmitted claims.
resubmitted claims.
resubmitted claims.

23

Enter the applicable quality


improvement organization
Enter prior authorization
prior authorization number,
Enter prior authorization
number, referral number,
referral number,
number, referral number,
mammography
mammography
mammography precertification precertification number, or
precertification number, or
number, or Clinical Laboratory Clinical Laboratory
Clinical Laboratory
Improvement Amendments
Improvement Amendments
Improvement Amendments
(CLIA) number, as assigned by (CLIA) number, as assigned by (CLIA) number, as assigned by
the payer fr the current
the payer for the current
the payer for the current
service.
service.
service.

24A

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

24B

Enter the appropriate two-digit


palce-of-service (POS) code to
identify the location where the
reported procedure or service
was performed.

Enter the appropriate twodigit palce-of-service (POS)


code to identify the location
where the reported procedure
or service was performed.

Enter the appropriate twodigit palce-of-service (POS)


code to identify the location
where the reported procedure
or service was performed.

Leave blank.

Leave blank.

24C

Leave Blank

24D

Enter the CPT or HCPCS level


Enter the CPT or HCPCS level II II code and applicable
code and applicable required required modifier(s) for
modifier(s) for procedures or
procedures or services
services performed
performed

Enter the CPT or HCPCS level


II code and applicable
required modifier(s) for
procedures or services
performed

24E

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

24F

Enter the fee charged for each Enter the fee charged for each Enter the fee charged for each
reported peocedure or
reported peocedure or
reported peocedure or
service(e.g. 55 00).
service(e.g. 55 00).
service(e.g. 55 00).

24G

Enter the number of days or


Enter the number of days or
Enter the number of days or
units for procedures or
units for procedures or
units for procedures or
services reported in Block 24D services reported in Block 24D services reported in Block 24D

24H

Leave Blank. This is reserved


for Medicaid claims.

Leave Blank. This is reserved


for Medicaid claims.

Leave Blank. This is reserved


for Medicaid claims.

24I

Leave blank. (The NPI


abbreviation is preprinted on
the CMS-1500 claim.)

Leave blank. (The NPI


abbreviation is preprinted on
the CMS-1500 claim.)

Leave blank. (The NPI


abbreviation is preprinted on
the CMS-1500 claim.)

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

24J

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier or
outside laboratory .

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier
or outside laboratory .

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier
or outside laboratory .

25

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

26

Enter the patients account


number as assigned by the
provider.

Enter the patients account


number as assigned by the
provider.

Enter the patients account


number as assigned by the
provider.

27

Enter an X in the YES box to


Enter an X in the YES box to
indicate th the provider agrees indicate th the provider
to accept assignment.
agrees to accept assignment.

Enter an X in the YES box to


indicate th the provider
agrees to accept assignment.

28

Enter the total charges


services and/or procedures
reported in Block 24.

Enter the total charges


services and/or procedures
reported in Block 24.

Enter the total charges


services and/or procedures
reported in Block 24.

29
30

Enter the total amount the


patient paid toward covered
services only. If no payment
was made, leave blank.
Leave blank.

Leave blank.
Leave blank.

Enter the total amount the


patient paid toward covered
services only. If no payment
was made, leave blank.
leave blank

31

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

32

Enter the name and address


where procedures or services
were provided.

Enter the name and address


where procedures or services
were provided.

32A
32B

Enter the 10-digit NPI of the


facility or supplier in Block 32
Leave blank.

Enter the 10-digit NPI of the


Enter the 10-digit NPI of the
facility or supplier in Block 32 facility or supplier in Block 32
Leave blank.
Leave blank.

33
33A
33B

Enter the name and address


where procedures or services
were provided.

Enter the providersd billing


Enter the providers billing
Enter the providers billing
name, address, and telephone name, address, and telephone name, address, and telephone
number.
number.
number.
Enter the 10-digit NPI of the
billing provider.
Leave blank.

Enter the 10-digit NPI of the


billing provider.
Leave blank.

Enter the 10-digit NPI of the


billing provider.
Leave blank.

Medicaid

Tricare

Worker's Comp

Enter an X in the Medicaid


box.
Enter the Mesicaid ID
numberas it aooears on the
paitents medicaid card

Enter the
SSN as Box
it
an Xsponsers
in the TRICARE
Enter an X in the FECA box.
apears on the reverse of the
uniformed services common
accses card.
Enter the patients SSN.

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

Leave Blank.
Pt's address & phone #

Enter the sponser's last name, Enter the name of the


first name, and middle initial. patients Employer.
Pt's address & phone #
Pt's address & phone #

Leave Blank.

X in box to indicate patient's


relationship

Enter an X in the other box.

Leave Blank.
Leave Blank.

Enter the sponser's mailing


address and telephone
number.
Leave Blank.

Enter the employers billing


address and telephone
number.
Leave blank.

Leave Blank.
Leave Blank.

Leave Blank.
Leave Blank.

Leave blank.
Leave blank.

Enter an X in the appropriate


box to indicate whether the
patient's condition is related
to employment, an auto
Enter X in appropriate box for accident, and/or another
Workers Comp or accident
axccident.

Pt's name LAST, FIRST, MI


DOB MMDDYYYY

Enter an X in the appropriate


box to indicate whether the
patient's condition is related
to employment, an auto
accident, and/or another
axccident. (Enter X in the yes
box on 10A.)

For medicaid managed care


programs, enter an E for
emergengy care , U for
urgency care.

If DD form 2527 is attached to


the CMS-1500 claim form,
enter DD 2527 ATTATCHED
Leave Blank.

Leave Blank.
Leave Blank.

Leave Blank.
Leave Blank.

Enter the nine digit FECA


number.
Leave Blank.

Leave Blank.

Leave Blank.

Enter the claim number


assigned by the workers'
cpmensationthird-party payer.

Leave Blank.

Leave Blank.

Enter the name of the


workers'compansation payer.

Leave Blank.
Leave Blank.

X in the NO box if no other


coverage
SIGNATURE ON FILE

Leave blank.
Leave blank.

Leave Blank.

Enter signature on file to


authorize direct payment to
the provider for benefits due
the patient.

Leave blank.

Leave Blank.

enter the date as mm dd yyyy enter the date as mm dd yyyy


to indicate when patient first to indicate when patient first
expierenced symtoms
expierenced symtoms

Leave Blank.

Enter the date as MM DD YYYY


to indicate that a prior
episode of the same illness
began.

Enter the date as MM DD YYYY


to indicate that a prior
episode of the same illness
began.

Leave Blank.

Leave Blank.

Leave Blank.

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave Blank.

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave Blank.

If appicable, enter first,


middle, last name, and
credentials of the refering
professional.
Leave Blank.

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

Enter the 10 digit national


provider identifer (NPI)of the
provider in block 17.
Otherwise leave blank

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave Blank.

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave Blank.

Enter the admission date and


discharge date if the patient
received inpatient services.
Leave Blank.

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an
outside laboratory.

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an
outside laboratory.

Enter an X in the NO box if all


laboratory procedures repoted
on the claim were performed
in the providers office. Mark
an X in the YES box if they
were performed my an
outside laboratory.

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or
medically managed during the
encounter.

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or
medically managed during the
encounter.

Enter the ICD-10-CM code for


up to 12 diagnoses or
conditions treated or
medically managed during the
encounter.

Leave blank. This reserved for Leave blank. This reserved for Leave blank. This reserved for
resubmitted claims.
resubmitted claims.
resubmitted claims.

Enter the Medicaid preauthorozation number, which


was assigned by the payer, if
applicable.

If applicable enter the prior


authorization number.

Enter the preauthorization


number assigned by the
workers compensation payer.

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

Enter the date the procedure


or service was performed in
the FROM column as MM DD
YYYY.

Enter the appropriate twodigit palce-of-service (POS)


code to identify the location
where the reported procedure
or service was performed.

Enter the appropriate twodigit palce-of-service (POS)


code to identify the location
where the reported procedure
or service was performed.

Enter the appropriate twodigit palce-of-service (POS)


code to identify the location
where the reported procedure
or service was performed.

Enter an E if the service was


provided for a medical
emergency, regaurdless of
where it was provided.

Leave Blank.

Leave Blank.

Enter the CPT or HCPCS level


II code and applicable
required modifier(s) for
procedures or services
performed

Enter the CPT or HCPCS level


II code and applicable
required modifier(s) for
procedures or services
performed

Enter the CPT or HCPCS level


II code and applicable
required modifier(s) for
procedures or services
performed

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

Enter the diagnosis pointer


letter from block 21 that
relates to the
procedure/service performed
on the date of service.

Enter the fee charged for each Enter the fee charged for each Enter the fee charged for each
reported peocedure or
reported peocedure or
reported peocedure or
service(e.g. 55 00).
service(e.g. 55 00).
service(e.g. 55 00).
Enter the number of days or
Enter the number of days or
Enter the number of days or
units for procedures or
units for procedures or
units for procedures or
services reported in Block 24D services reported in Block 24D services reported in Block 24D

Enter an E if the service was


provided under the EPSDT
program, or enter an F if the
service was provided for a
family planning . Enter a B if
the service can be categorized
as both EPSDT and family
planning.
Leave Blank.

Leave Blank.

Leave blank. (The NPI


abbreviation is preprinted on
the CMS-1500 claim.)

Leave Blank.

Leave Blank.

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier
or outside laboratory .

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier
or outside laboratory .

Enter the 10-digit NPI for the


Provider who performed the
service, the Supervising
provider, or DMEPOS suplier
or outside laboratory .

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

Enter the providers Social


Security number (SSN) or
employer identification
number (EIN) No spaces or
hypens.

Enter the patients account


number as assigned by the
provider.

Enter the patients account


number as assigned by the
provider.

Enter the patients account


number as assigned by the
provider.

Enter an X in the YES box to


indicate th the provider
agrees to accept assignment.

Enter an X in the YES box to


indicate th the provider
agrees to accept assignment.

Enter an X in the YES box to


indicate th the provider
agrees to accept assignment.

Enter the total charges


services and/or procedures
reported in Block 24.

Enter the total charges


services and/or procedures
reported in Block 24.

Enter the total charges


services and/or procedures
reported in Block 24.

Leave Blank.
Leave Blank.

Leave Blank.
Leave Blank.

Leave Blank.
Leave Blank.

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

Enter the providers name and


credential and the date the
claim was completed as
MMDDYYYY (without spaces)

Enter the name and address


where procedures or services
were provided.

Enter the name and address


where procedures or services
were provided.

Enter the name and address


where procedures or services
were provided.

Enter the 10-digit NPI of the


Enter the 10-digit NPI of the
Enter the 10-digit NPI of the
facility or supplier in Block 32 facility or supplier in Block 32 facility or supplier in Block 32
Leave Blank.
Leave Blank.
Leave Blank.
Enter the providers billing
Enter the providers billing
Enter the providers billing
name, address, and telephone name, address, and telephone name, address, and telephone
number.
number.
number.
Enter the 10-digit NPI of the
billing provider.
Leave Blank.

Enter the 10-digit NPI of the


billing provider.
Leave Blank.

Enter the 10-digit NPI of the


billing provider.
Leave Blank.