Commercial

Insurance

Block
1

1a
2
3
4
5
6
7
8

x - other for ind/family plan

x - group plan

BCBS

Medicare
x - in medicare box

Medicaid

enter x in
TRICARE/CHAMPUS
enter x in madicaid box box
enter sponsor's
social security
number as it
appears on the
reverse of the
uniformed services
common access
card.

ID #
Pt's
name
LAST, FIRST, MI
patients
birthdate
x - to indicate
gender
policy holder's last name, first
name, and middle initial
patients mailing address and
telephone number
x- to indicate the patients
relationship to policy holder
policyholder's mailing address
and telephone number
leave blank

leave blank. Blocks 9, 9a, and

9d are completed if the patient
has secondary insurance
9, 9a, 9d coverage
9b-9c leave blank

Tricare

leave blank

leave blank

leave blank

leave blank
leave blank

leave blank
leave blank

leave blank
leave blank

leave blank
leave blank

leave blank

leave blank

10a-c

10d

enter x in the appropriate box

to indicate whether the
patients condition is related to
employment, an automobile
accident, and/or another type
of accident.

11

leave blank
policyholder's commercial
group number if the patient is
covered by a group health plan

11a

policyholder's birth date as MM

DD YYYY
x - to indicate
policyholder's gender

11b

12

leave blank.
policyholder's commercial
health insurance plan
x- in the NO box (if patient
does not have a secondary
insurance coverage)
enter SIGNATURE ON FILE.
Leave the date field blank

13

enter SIGNATURE ON FILE to

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

11c

11d

enter x in the NO box

enter X in the NO boxes

leave blank

if DD form 2527 is
attched to the
cmd-1500 claim
enter DD form
2527 attached.
Otherwise leave
blank

enter NONE

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

enter x in NO box

leave blank

leave blank

leave blank

leave blank

14

date when the patient first

experienced sings or
symptoms of present illness,
actual date of injury, or the
date of last menstrual period
for obstetric visits.

15

date to indicate that prior

epidode of the same or similar
illness began, if documented in
the patients record.
leave blank

16

date to indicate the period of

time the patient was unable to
work in his current occupation
if documented in the patients
record.
leave blank

17
17a
17b
18
19

if applicable, enter first name,

middle initial, lastname, and
credentials of the professional
who referred, ordered, or
supervised health care
services or supplies reported
on the claim
leave blank
10-digit national provider
indentifier (NPI)
admission date and dischare
date
leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

leave blank

20

x - in no box if all lab

procedures reported were
performed in the provider's
office.
X - in
the yes box if lab procedures
reported were performed by
and outside laboratory
enter total
amount charged by the outside
lab in $CHARGES, and enter
outside lab's name, mailing
address, and NPI in block 32

21
22

enter ICD-10-CM code for up to

12 diagnoses or conditions
treated or medically managed
during the encounter.
leave blank

23

enter prior autorization

number, referral number,
mammography precertification
number, or clinical laboratory
improvement amendments
number as assigned by the
payer for the current service.

24b

date service was performed in

the FROM colum. Enter a date
in the TO column if the
procedure or service was
performed on consecutive days
during a range of dates.
enter two digit place of service
POS

24c

leave blank

24a

E if service was
provided for medical
emergency regardless
of where it was
provided

24d

24e
24f

24g

24h
24l

24j

25
26

enter CPT or HCPCS level II

code and applicable required
modifiers for procedures or
services performed
enter diagnosis pointer letter
from block 21 that relates to
the procedure/serivice
performed
enter the fee charged for each
reported procedure/service.
enter number of days or units
for procedures or services
reported in block 24d

leave blank. Reserved fo

medicaid claims
leave blank.
10 digit NPI for provider or
supervising provider or
DMEPOS supplier or outside
laboratory
enter provider's social security
number or eployer
identification
enter patient'snumber
account
number as assigned by the
provider

enter E if ther service

was provided under
the EPSDT program or
enter F if the service
was provided for
family planning. Enter
B if the service can be
categorized as both
EPSDT and family
planning, otherwise
leave blank
leave blank
leave blank

27

28
29
30

31

32
32a
32b
33
33a
33b

enter x - in the YES box to

indicate that the provider
agrees to accept assignment.
Otherwise, enter x - in the NO
box
total charges for services
and/or procedured reported in
block 24
total amount the patient paid
toward covered services only. leave blank
leave blank
leave blank
provider's name and credential
and the date the claim was
complete.
name and address where
procedures or services were
provided if other than
provider's office or the
patient's home
10 digit NPI of the facility or
supplier entered in block 32
leave
blank
provider's
billing name,
address, and telephone
number
10 digit NPI of billing provider
leave blank

leave blank
leave blank

leave blank

leave blank
leave blank

Worker's Comp
enter x in FECA box

enter patients social security

number

enter name of the patients

employer

enter x in other box

enter employers mailing address
leave blank

leave blank

enter YES in in 10a

enter nine digit FECA number

leave blank
enter claim number assined
by the worker's
compensation third party
payer
enter the name of the
worker's compensation payer

leave blank
leave blank

leave blank

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leave blank

leave blank
leave blank