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March 18, 2008

CMS-1500 (08/05) Data Element Requirements

The following information discusses the conditions and requirements of the item fields within the CMS-1500 (08/05) paper claim form.
Status Key:
R = Completion of this item is required by Medicare
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare
Note: Effective May 23, 2007, claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.

Item Number
Item Description
Requirement Status
1
Type of insurance
R
1a
Patient’s Medicare Health Insurance Claim #
R
2
Enter patient’s last name, first name, and middle initial, if any, as shown on patient’s Medicare card.
R
3
Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex.
R
4
Insured’s Name
C
5
Patient’s Mailing Address, City, State, and Phone Number
R
6
Check the appropriate box for patient’s relationship to insured when item 4 is completed.
C
7
Insured’s address and telephone number. When the address is the same as the patient’s, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.
C
8
Patient’s Marital Status and whether employed or a student
NR
9-9d
Medigap Information
C
10a-c
Employment/Accident Indicators
R
10d
Medicaid
C
11
Primary Insurance policy number (Enter the word NONE if Medicare is primary)
R
11a-c
Insured’s Birth Date, Employer, Plan Name
C
11d
Leave Blank
NR
12
Patient’s Signature and Date
R
13
Patient Signature - Medigap Authorization
C
14
Date of Current Illness
C
15
Same or Similar Illness
NR
16
If patient is employed, enter dates patient unable to work in current occupation.
C
17
Enter the name of the referring or ordering physician if the item or service was ordered or referred by a physician.
C
17a
Enter “1G” and a space, followed by the UPIN of the referring/ordering physician. This may be reported until May 23, 2008.
C
Required if services ordered/referred
17b
Enter the NPI of the referring/ordering physician, if available. The NPI is required on all claims on and after May 23, 2008.
C
Required if services ordered/referred
18
Hospitalization Dates
C
19
Narrative Information
C
20
Outside Lab
C
21
Diagnosis
R
22
Leave Blank
NR
23
Prior Authorization Number
(See CMS IOM Pub 100-04, Chapter 26, Sec 10.4 for guidance)
C
24A
Date of Service
R
24B
Place of Service
(See CMS IOM Pub 100-04, Chapter 26, Sec 10.5 for codes and definitions)
R
24C
Medicare Part B Providers are not required to complete.
NR
24D
Procedure Code/Applicable Modifiers
R
24E
Diagnosis Pointer
R
24F
Charge for Service
R
24G
Days/Units
R
24H
Leave Blank
NR
24I
Enter the ID qualifier “1C” if reporting a Legacy number/PIN. Do not report on and after May 23, 2008.
C
24J
Enter the rendering provider’s Legacy number/PIN in the shaded portion. Do not report the PIN on and after May 23, 2008.
If available, enter the NPI of the rendering provider in the lower non-shaded portion. The NPI is required as of March 1, 2008.
C
25
Federal Tax ID#
C
26
Patient’s Account Number
C
27
Assignment
R
28
Total Charges
R
29
Enter amount collected from Patient, if any.
C
30
Leave Blank
NR
31
Provider Signature and Date
R
32
Name, address and ZIP of location where services were rendered for all locations other than in the patient’s home – Place of Service (POS) 12.
R
32a
If reporting purchased diagnostic services, enter the NPI (if available) of the provider who performed the service. The NPI is required as of May 23, 2008.
On/after October 1, 2007, DO NOT report for providers outside of local jurisdiction. Report the NPI of the provider who purchased the service instead.
C
32b
If reporting purchased diagnostic services, enter the Legacy number/PIN of the performing service provider.
On/after October 1, 2007, DO NOT report for provider outside of local jurisdiction. Report the Legacy number/PIN of the provider who purchased the service instead. Do not report the Legacy number/PIN on and after May 23, 2008.
C
33
Billing Provider’s name, address, ZIP and telephone number
R
33a
If available, enter the NPI of the billing provider. The NPI is required as of March 1, 2008.
R
33b
Enter the Legacy number/ PIN of the billing provider. Do not report the Legacy number/PIN on and after May 23, 2008.
R
Source: CMS IOM Pub 100-04 –Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.1.1 & 80.3.2.1.2; Chapter 26, Section 10; Joint Signature Memorandum (JSM) 08048 (November 14, 2007) – Mandatory Reporting of the National Provider Identifier (NPI) on all Part B Claims; Change Request (CR) 5858 – Medicare Fee For Service Legacy Provider IDs Prohibited on Form CMS-1500 Claims after NPI Required Date; CR 5890 – Additional Information on Reporting a National Provider Identifier (NPI) for Ordering/Referring and Attending/Operating/Other/Service facility for Medicare Claims.
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