Cms-1500 Form

Front 1

Block 1

Back 1

Check the box indicating what kind of insurance is applicable sure as Medicare

Front 2

Block 1A

Back 2

The patient's Medicare health insurance claim number (HICN). This number must be recorded whether Medicare is the primary or secondary payor.

Front 3

Block 2

Back 3

The patient's first name, middle initial (if any), and last name, as shown on the patient Medicare card.

Front 4

Block 3

Back 4

The patient's eight-digit birth date (recorded as MM\DD\CCYY) and sex. For example: September 28,1990, would be recorded: 09\28\1990.

Front 5

Which of the following blocks on the CMS-1500 claim form is required to indicate a workers' compensation claim?

Back 5

Block 10a

Front 6

On the CMS-1500 claim form, Block 1 through 13 include which of the following?

Back 6

The patient's demographic

Front 7

Which is the maximum number of ICD codes that can be entered on a CMS-1500 claim form as of February 2012?

Back 7

12

Front 8

Which of the following blocks on the CMS-1500 claim form is used to bill ICD codes?

Back 8

Block 21

Front 9

If there is an insurance primary to Medicare, obtained through the patient's or spouse's place of work or through any other source, list the name of the insured here. If the patient and the insured are the same, write SAME. If Medicare is primary, leave this field blank.

Back 9

Block 4

Front 10

The patient's mailing address and telephone number. Put the mailing address on the first line, the city ans state on the second line, and the ZIP code and phone number on the third line.

Back 10

Block 5

Front 11

Check the appropriate box to patient's relationship to the insured.

Back 11

Block 6

Front 12

Enter the insured's address and phone number. If the insured is the same as the same as the patient, write SAME. Complete this block only after blocks 4, 6, and 11 have been completed

Back 12

Block 7

Front 13

Leave blank.

Back 13

Block 8

Front 14

CMS-1500 Form blocks 9-13

Back 14

CMS-1500

Front 15

Accepting assignment on the CMS-1500 claim form indicates which of the following?

Back 15

The physician agrees to accept payment under the terms of the payer's program.

Front 16

Which of the following information should the billing and Coding Specialist input into Block 33a on the CMS-1500 claim form?

Back 16

National provider identification number

Front 17

Write the last name, first name, and middle initial (if any) of the Medigap enrollee if it is a different person from the one listed in block 2. Otherwise, write SAME. If no medigap benefits are assigned, leave blank.

Back 17

Block 9

Front 18

Enter the policy and group number of the medigap insured preceded by MEDIGAP, MG, or MGAP.

Back 18

Block 9a

Front 19

Leave blank

Back 19

Block 9 B

Front 20

Block 9c

Back 20

Leave blank if block 9d is filled out. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code from Medigap insurer's identification card. For example,1234 Park Avenue, New York, New York 20072 should be written as 1234 Park Ave. NY 20072

Front 21

Write in the coordination of benefits Agreement Medigap-based identifier.

Back 21

Block 9d

Front 22

Check "Yes" or "No" to indicate whether employment, Auto liability, or other accident involvement applies to one or more of the services listed in block 24. A "yes" answer indicates there might be other insurance primary to Medicare.

Back 22

Block 10a-c