CMS-1500 Complete review
Claim Form
The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims.
The top right margin of the claim form should NOT contain:
any type of adhesive-backed label
printing or headings (including the Medicare carrier address)
ink, markers, whiteout, etc.
Please print legibly or type all information. Claims may also be computer-prepared.
BLOCK 1
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.
Completion of this field is required for all claims.
BLOCK 1A INSURED’S I.D. NUMBER (For Program in Block 1)
Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
Completion of this field is required for all claims.
BLOCK 2 PATIENT’S NAME
Enter the patient’s last name, first name, and middle initial, if any, exactly as shown on the patient’s Medicare card.
Completion of this field is required for all claims.
BLOCK 3 PATIENT’S BIRTH DATE AND SEX
Enter the patient’s birth date (MMDDCCYY) and sex.
Completion of this field is required for all claims.
BLOCK 4 INSURED’S NAME
If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word “SAME”. If there is no insurance primary to Medicare, leave blank.
Completion of this field is conditional for insurance information.
BLOCK 5 PATIENT’S ADDRESS
Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.
Completion of this field is required for all claims; address and telephone must be indicated.
BLOCK 6 PATIENT RELATIONSHIP TO INSURED
Check the appropriate box for patient’s relationship to the insured when block 4 is completed.
Completion of this field is conditional for insurance information when block 4 is completed.
BLOCK 7 INSURED’S ADDRESS
Enter the insured’s address and telephone number. When the address is the same as the patient’s, enter the word SAME. Complete this block only when blocks 4 and 11 are completed.
Completion of this field is conditional for insurance information when blocks 4 and 11 are completed.
BLOCK 8 PATIENT STATUS
Check the appropriate box for the patient’s marital status and whether employed or a student.
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