The CMS-1500 Form - Fields 1–13: Patient and Insured Information
Field 13 - Insured’s or Authorized Person’s Signature
The “Insured’s or Authorized Person’s Signature” indicates that there is a signature on file authorizing payment of medical benefits. NUCC INSTRUCTIONS: Enter “Signature on File,” “SOF,” or legal signature. If there is no signature on file, leave ...
Field 12 - Patient’s or Authorized Person’s Signature
The “Patient’s or Authorized Person’s Signature” indicates there is an authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim. NUCC INSTRUCTIONS: Enter “Signature on File,” “SOF,” or ...
Field 11 d - Is There Another Health Benefit Plan
“Is there another health benefit plan” indicates that the patient has insurance coverage other than the plan indicated in Item Number 1. NUCC INSTRUCTIONS: When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9a, and 9d. Only ...
Field 11 c - Insurance Plan Name or Program Name
The “Insurance Plan Name or Program Name” is the name of the plan or program of the insured as indicated in Item Number 1a. NUCC INSTRUCTIONS: Enter the name of the insurance plan or program of the insured. Some payers require an identification ...
Field 11 b - Other Claim ID
The “Other Claim ID” is another identifier applicable to the claim. NUCC INSTRUCTIONS: Enter the “Other Claim ID.” Applicable claim identifiers are designated by the NUCC. When submitting to Property and Casualty payers, e.g. Automobile, Homeowner’s, ...
Field 11 a - Insured's Date of Birth, Sex
Field 11a of the CMS 1500 claim form, the “Insured’s Date of Birth, Sex” is the birth date and gender of the insured as indicated in Item Number 1a. NUCC INSTRUCTIONS: Enter the 8-digit date of birth (MM│DD│YYYY) of the insured and an X to indicate ...
Field 11 - Insured's Policy, Group or FECA Number
The “Insured’s Policy, Group, or FECA Number” is the alphanumeric identifier for the health, auto, or other insurance plan coverage. The FECA number is the 9-character alphanumeric identifier assigned to a patient claiming work-related condition(s) ...
Field 10 d - Claim Codes
The “Claim Codes” identify additional information about the patient’s condition or the claim. NUCC INSTRUCTIONS: When applicable, use to report appropriate claim codes. Applicable claim codes are designated by the NUCC. Please refer to the most ...
Fields 10 a - 10 c - Is Patient’s Condition Related To:
This information indicates whether the patient’s illness or injury is related to employment, auto accident, or other accident. “Employment (current or previous)” would indicate that the condition is related to the patient’s job or workplace. “Auto ...
Field 9 d - Insurance Plan Name or Program Name
The “Insurance Plan Name or Program Name” identifies the name of the plan or program of the other insured as indicated in Item Number 9. NUCC INSTRUCTIONS: Enter the other insured’s insurance plan or program name. MEDICARE INSTRUCTIONS - Enter the ...
Field 9 c - Reserved for NUCC Use
Field 9c of the CMS 1500 form is reserved for NUCC use. Leave Blank MEDICARE INSTRUCTIONS - Leave blank if item 9d is completed. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter ...
Field 9 b - Reserved for NUCC Use
Field 9b of the CMS 1500 form is reserved for NUCC use. Leave Blank MEDICARE INSTRUCTIONS - Leave blank.
Field 9 a - Other Insured's Policy or Group Number
NUCC INSTRUCTIONS -The “Other Insured’s Policy or Group Number” identifies the policy or group number for coverage of the insured as indicated in Item Number 9. Enter the policy or group number of the other insured. Do not use a hyphen or space as a ...
Field 9 - Other Insured's Name
The “Other Insured’s Name” indicates that there is a holder of another policy that may cover the patient. NUCC INSTRUCTIONS: If Item Number 11d is marked, complete fields 9, 9a, and 9d, otherwise leave blank. When additional group health coverage ...
Field 8 - Reserved for NUCC Use
NUCC INSTRUCTIONS: This field was previously used to report "Patient Status." "Patient Status" does not exist in 5010A1, so this field has been eliminated. This field is reserved for NUCC use. The NUCC will provide instructions for any use of this ...
Field 7 - Insured Address
The “Insured’s Address” is the insured’s permanent residence, which may be different from the patient’s address in Item Number 5. NUCC INSTRUCTIONS: Enter the insured’s address. If Item Number 4 is completed, then this field should be completed. The ...
Field 6 - Patient Relationship to Insured
The “Patient Relationship to Insured” indicates how the patient is related to the insured. “Self” would indicate that the insured is the patient. “Spouse” would indicate that the patient is the husband or wife or qualified partner, as defined by the ...
Field 5 - Patient's Address (multiple fields)
Field 5 - The “Patient’s Address” is the patient’s permanent residence. A temporary address or school address should not be used. NUCC INSTRUCTIONS: Enter the patient’s address. The first line is for the street address; the second line, the city and ...
Field 4 - Insured's Name
The “Insured’s Name” identifies the person who holds the policy, which would be the employee for employer-provided health insurance. NUCC INSTRUCTIONS: Enter the insured’s full last name, first name, and middle initial. If the insured uses a last ...
Field 3 - Patient's Birth Date
Field 3, the “Patient’s Birth Date, Sex” is information that will identify the patient and it distinguishes persons with similar names. NUCC INSTRUCTIONS: Enter the patient’s 8-digit birth date (MM | DD | YYYY). Enter an X in the correct box to ...
Field 2 - Patient's Name
Field 2 on the CMS 1500 claim form is for the Patient's Name. The “Patient’s Name” is the name of the person who received the treatment or supplies. NUCC INSTRUCTIONS: Enter the patient’s full last name, first name, and middle initial. If the patient ...
Field 1a - Insured's ID Number
Field 1a is the Insured's ID Number. This information identifies the insured to the payer. NUCC INSTRUCTIONS: Enter the insured’s ID number as shown on insured’s ID card for the payer to which the claim is being submitted. If the patient has a unique ...
Field 1 - Type of Insurance Coverage
Field 1 is where you indicate the type of insurance coverage your patient has. “Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other” means the insurance type to which the claim is being submitted. “Other” indicates health ...