Completing the CMS-1500 Claim Form Below are instructions for filling out a CMS-1500 Claim Form (version 08/05) when submitting a claim to CareFlorida. Each field on the form is described, and all required fields are marked. Required fields must be completed legibly and accurately in order to submit a clean claim. 1. Type of Health Insurance Required. Check the box labeled OTHER. 1a. INSURED S I.D. NUMBER Required. Enter the CareFlorida Member ID number. The Member ID is 11 characters long and consists of the letter P followed by 10 digits. 2. PATIENT S NAME Required. Enter patient s name in this order: LAST FIRST MIDDLE INITIAL as shown on the patient s Medicaid card. 3. PATIENT S BIRTH DATE Required. Enter the patient s date of birth as follows: SEX MM = Month of birth (01 to 12) DD = Day of birth (01 to 31) YY = Year of birth. NOTE: You must use 4 digits (for example, 1945 ). Required. Check M or F to enter the patient s sex. 4. INSURED S NAME Required if Medicaid is not primary insurance. When there is insurance primary to Medicaid (for example, through the patient or spouse s employment: - if the insured and the patient are the same, enter the word SAME; or - if the insured is not the same as the patient, enter the insured s name, as follows: LAST FIRST MIDDLE INITIAL 5. PATIENT S ADDRESS Enter the patient s street CareFlorida Provider Manual 8-8
CITY STATE ZIP CODE TELEPHONE Enter the city portion of the patient s Enter the state portion of the patient s Enter the zip code portion of the patient s Enter the patient s telephone number, including the area code. Enter numbers only, no dashes or parentheses. 6. PATIENT RELATIONSHIP Required if item 4 is not blank. Check the TO INSURED box to indicate the patient s relationship to the insured. 7. INSURED S ADDRESS Required if item 4 is not blank. Enter the insured s street CITY STATE ZIP CODE TELEPHONE Enter the city portion of the insured s Enter the state portion of the insured s Enter the zip code portion of the insured s Enter the insured s telephone number, including the area code. Enter numbers only, no dashes or parentheses. 8. PATIENT STATUS Check the appropriate boxes to indicate marital and employment status of the patient. 9. OTHER INSURED S NAME Leave this item blank (including fields 9a, 9b, 9c, 9d). 10. PATIENT S CONDITION For fields a, b and c, check the YES or NO box to indicate whether employment, automobile, or any other accident is related to the services being claimed. If an auto accident is involved, enter the state postal code in the PLACE field. 10d. RESERVED FOR LOCAL USE Leave this field blank. CareFlorida Provider Manual 8-9
11. INSURED S POLICY GROUP Required. If there is no insurance primary OR FECA NUMBER to Medicaid, enter the word NONE and go on to item 12. INSURED S DATE OF BIRTH If there is insurance primary to Medicaid, enter the insured s policy or group number and complete fields 11a through 11c. Required if item is 4 not blank, and item 6 is not SELF. Enter the insured s date of birth using the same formatting as item 3, above. SEX Required, if item 4 not blank, and item 6 is not SELF. Check M or F to enter the insured s sex. 11b. EMPLOYER S NAME Enter the insured s employer s name, if applicable. If the insured s insurance status has changed (for example, due to retirement), enter the date of the change, preceded by the word RETIRED. 11c. INSURANCE PLAN NAME Required if item 4 is not blank. Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID numbers exist, enter the complete primary payer s program or plan name. If the primary payer s EOB does not contain the claims processing address, enter the primary payer s claims processing address directly on the EOB. 11d. ANOTHER HEALTH PLAN Leave blank. 12. PATIENT S SIGNATURE Enter SIGNATURE ON FILE. 13. INSURED S SIGNATURE Enter SIGNATURE ON FILE. 14. DATE OF CURRENT Enter date of current illness or injury as 6 ILLNESS or 8 digits, depending on which format you are using. 15. SAME OR SIMILAR ILLNESS Leave this field blank. 16. DATES PATIENT UNABLE Enter dates patient is unable to work as 6 TO WORK or 8 digits, depending on which format you are using. CareFlorida Provider Manual 8-10
17. NAME OF REFERRING Required. Enter the name of the referring PROVIDER provider, if applicable. 17a. Leave this field blank. 17b. NPI Required. Enter the NPI of the referring provider. 18. HOSPITALIZATION DATES Enter dates when a service was furnished as a result of, or subsequent to, a related hospitalization. Enter the dates as 6 or 8 digits, depending on which format you are using. 19. RESERVED FOR LOCAL USE Only use this field when reporting an unlisted procedure code, or a not otherwise classified code. For these codes, enter a narrative description in item 19, if a coherent description can fit within the box. Otherwise, leave this field blank. 20. OUTSIDE LAB Check the box labeled NO. 21. DIAGNOSIS Required. Enter the code(s) indicating the patient s diagnosis or nature of illness/injury. Except for ambulance suppliers, all physician and non-physician specialties use an ICD-9-CM code number and code to the highest level of specificity. Enter up to 4 diagnoses in order of priority. All narrative diagnoses for nonphysician specialties must be submitted on an attachment. 22. MEDICAID RESUBMISSION Leave this field blank. 23. PRIOR AUTHORIZATION Enter Authorization Number, when applicable. Enter numbers only; no dashes, spaces or commas. 24. In this section, list the details for up to 6 services, supplies or procedures, as follows: 24a. DATE(S) OF SERVICE Enter date(s) for the procedure, service or supply as 6 or 8 digits, depending on which format is being used. When entering dates for a series of identical services, be CareFlorida Provider Manual 8-11
sure to enter the number of days or units in 24g. NOTE: If the date of service is longer than 1 day, and there is no valid To date, the claim cannot be processed. 24b. PLACE OF SERVICE Required. Enter the 2-digit place of service code. 24c. EMG Leave this field blank. 24d. PROCEDURES, SERVICES Required. Enter the specific procedure OR SUPPLIES code as described below: CPT/HCPCS MODIFIER Enter either the CPT code (5-digit numeric), or the HCPCS code (5-place alphanumeric) for the service. Enter the 2-digit modifiers (up to 4) for the procedure code. 24e. DIAGNOSIS POINTER Required. Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service. This number will be 1, 2, 3, or 4. 24f. $ CHARGES Required. Enter the charge for each listed service. Enter numbers and decimal points only; do not enter dollar signs. 24g. DAYS OR UNITS Required. Enter the number of days or units. If only one service is performed, you must enter the numeral 1. 24h. EPSDT Leave this field blank. 24i. ID QUAL Leave this field blank. 24j. RENDERING PROVIDER Required. Enter the rendering provider s ID # NPI number in the lower unshaded portion. 25. FEDERAL TAX I.D. NUMBER Required. Enter the provider of service or supplier Federal Tax I.D. (Employer Tax Identification number or Social Security Number), and check the appropriate box. Reimbursement of claim submitted without tax identification information will be delayed. CareFlorida Provider Manual 8-12
26. PATIENT S ACCOUNT Enter the patient s account number NUMBER assigned by the provider s or supplier s accounting system, if applicable. 27. ACCEPT ASSIGNMENT? Required. Check YES or NO to indicate whether the provider or supplier accepts assignment of Medicaid benefits. 28. TOTAL CHARGE Required. Enter a total charge amount for all the services listed in column 24f. 29. AMOUNT PAID Required if the amount is not 0. Enter the total amount the patient paid on the covered services. 30. BALANCE DUE Leave this field blank. 31. SIGNATURE Complete this field according to CMS guidelines. 32. SERVICE FACILITY Required. If a place of service code other LOCATION INFORMATION than 12 ( Home ) is listed in item 24B, enter the name, address, and zip code of the location where the service was provided. 32a. If available, enter the NPI of the service facility. 32b. Leave this field blank. 33. BILLING PROVIDER INFO Required. Enter the name, address, and & PH # zip code of the provider of service. 33a. Required. You must enter the provider s NPI. 33b. Leave this field blank. CareFlorida Provider Manual 8-13