Note: If a provider of service or supplier
chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19 or 24a,
he or she must enter 8-digit dates for all these fields. For
instance, a provider of service or supplier will not be
permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a
6-digit date for item 24a. The same applies to providers of service
and suppliers who choose to submit 6-digit dates too. Items 12 and
31 are exempt from this requirement.
|Item 1 (Type of Insurance):
Show the type of health insurance coverage applicable to
this claim by checking the appropriate box(es), e.g., if a
Medicare claim is being filed, check the Medicare box. If
the claim involves a Medicaid crossover, mark both the
Medicare and Medicaid boxes.
|Item 1 a (Insured's ID Number):
Enter the patient's Medicare Health Insurance Claim
Number (HICN) whether Medicare is the primary or secondary
payer. Enter the number as shown on the patient's Medicare
card. Be sure to include the alpha character(s).
|Item 2 (Patient's Name):
Enter the patient's last name, first name and middle
initial, if any, as shown on the patient's Medicare card.
|Item 3 (Patient's Birth date):
Enter the patient's 8-digit date of birth and sex.
Use the format MM/DD/CCYY.
|Item 4 (Insured's Name):
If there is insurance primary to Medicare, either
through the patients 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
Medicare is primary, leave blank.
|Item 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 phone number.
|Item 6 (Patient’s Relationship to
Check the appropriate box for the patient's relationship
to the insured when item 4 is completed.
|Item 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 item only when items 4 and 11
|Item 8 (Patient Status):
Check the appropriate box for the patient's marital
status and whether employed or a student.
|Item 9 (Other Insured's Name):
Enter the last name, first name and middle initial of
the enrollee in a Medigap policy, if it is
different from that shown in item 2. Otherwise, enter the
word SAME. If no Medigap benefits are assigned, leave blank.
Note on ltem 9 P-- Only participating
physician and suppliers are to complete item 9 and its
subdivision, and only when the beneficiary wishes to assign
his/her benefits under a Medigap policy to the participating
physician or supplier.
Participating physicians and
suppliers must enter information required in item 9 and its
subdivisions, if requested by the beneficiary. Participating
physicians/suppliers sign an agreement with Medicare to
accept assignment of Medicare benefits for all
Medicare patients. A claim for which a beneficiary elects to
assign his/her benefits under a Medigap policy to a
participating physician/supplier is called a mandated
Medigap. A Medigap policy meets the statutory
definition of a "Medicare supplemental policy" contained in
§1882(g)(1) of title XVIII of the Social Security Act (the
Act) and the definition contained in the NAIC Model
Regulation that is incorporated by reference to the statute.
It is a health insurance policy or other health benefit plan
offered by a private entity to those persons entitled to
Medicare benefits and is specifically designed to supplement
Medicare benefits. It fills in some of the "gaps" in
Medicare coverage by providing payment for some of the
charges for which Medicare does not have responsibility due
to the applicability of deductibles, coinsurance amounts, or
other limitations imposed by Medicare. It does not include
limited benefit coverage available to Medicare beneficiaries
such as "specified disease" or "hospital indemnity"
coverage. Also, it explicitly excludes a policy or plan
offered by an employer to employees or former employees, as
well as that offered by a labor organization to members or
Do not list other supplemental coverage in item 9 and its
subdivisions at the time a Medicare claim is filed. Other
supplemental claims are forwarded automatically to the
private insurer, if the private insurer contracts with
Medicare Services to send Medicare claim information
electronically. If there is no such contract, the
beneficiary must file his/her own supplemental claim.
|Item 9 a:
Enter the policy and/or group number of the Medigap
enrollee preceded by the word "MEDIGAP", "MG" or "MGAP". If
you bill electronically, enter the policy and or group
number in NSF fields DA0.18 (Insured ID) and/or DA0.10
(Group #) followed by MG in the DA0.06 field (Ins Type
Note: Item 9d must be completed if a policy and/or
group number is in item 9a.
|Item 9 b:
Enter the Medigap insured’s 8-digit date of birth and
sex. Use the format MM/DD/CC/YY.
|Item 9 c:
Disregard "employer's name or school name" which is
printed on the form. Enter the claims processing address for
the Medigap insurer. Use an abbreviated street address, two
letter State postal code, and zip code copied from the
Medigap enrollee's Medigap identification card: For
example:1257 Anywhere Street; Baltimore, Maryland 21204
is shown as "1257 Anywhere St. MD 21204."
a carrier assigned unique identifier of a Medigap
insurer appears in item 9d, item 9c may be left blank.
|Item 9 d:
The 9-digit PAYERID number of the Medigap insurer. If no
PAYERID number exists, then the Medigap insurance program or
plan name is shown.
If a participating provider of service
or supplier and the patient wants Medicare payment data
forwarded to a Medigap insurer under a mandated Medigap
transfer, all of the information in items 9, 9a, 9b, and 9d
must be complete and accurate. Otherwise, you cannot forward
the claim information to the Medigap insurer.
|Items 10 a -10 c (Patient's Condition
Check "YES" or "NO" to indicate whether employment, auto
liability or other accident involvement applies to one or
more of the services described in item 24. The state postal
code, (i.e. MO) must be shown. Any item checked "YES"
indicates there may be other insurance primary to Medicare.
Primary insurance information must then be shown in item 11.
|Item 10 d:
Use this item exclusively for Medicaid (MCD)
information. If the patient is entitled to Medicaid, this
item must show the patient's Medicaid number, preceded by
|Item 11: (Insured's Policy Number):
This item must be completed. By completing this item, the
physician/supplier acknowledges having made a good faith
effort to determine whether Medicare is the primary or
If there is insurance primary to
Medicare, enter the insured's policy or group number and
proceed to items 11a -11c. Items 4, 6 and 7 must also be
Note: The appropriate information in item 11c is
shown if insurance primary to Medicare is indicated in item
11. If there is no insurance primary to Medicare, enter the
word "NONE" and proceed to item 12. If the insured reports a
terminating event with regard to insurance which had been
primary to Medicare (e.g., insured retired), enter the word
"NONE" and proceed to item 11b.
Insurance primary to Medicare: Circumstances under
which Medicare payment may be secondary to other insurance
- Group Health Plan Coverage:
- Working Aged;
- Disability — (Large Group Health Plan); and
- End Stage Renal Disease,
- No Fault and/or Other Liability,
- Work-Related Illness/Injury:
- Workers' Compensation;
- Black Lung; and
- Veterans Benefits
Note: For a paper claim to be considered
for Medicare Secondary Payer benefits, a copy of the primary
payer's explanation of benefits (EOB) must be forwarded
along with the claim form.
|Item 11 a:
The insured’s 8-digit birth-date (MM/DD/CCYY) and sex if
different from item 3.
|Item 11 b:
Enter employer's name, if applicable. If there is a
change in the insured's insurance status, (e.g., retired),
enter either a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY)
retirement date preceded by the word "RETIRED." If you bill
electronically, enter the information in NSF field DA2.10
(retire date) and DA2.12 (insured’s employer name).
|Item 11 c:
The 9-digit PAYERID number of the primary insurer. If no
PAYERID number exists, then enter the complete primary
payer’s program or plan name. If the primary payer’s EOB
does not contain the claims processing address, record the
primary payer’s claims processing address directly on the
EOB. This is required if there is insurance primary to
Medicare that is indicated in Field 11.
|Item 11 d:
Leave blank. Not required by Medicare.
|Item 12 (Signature):
The patient or authorized representative must sign and
date and enter either a 6-digit date (MM/DD/YY), 8-digit
date (MM/DD/CCYY), or an alphanumeric date (e.g., January 1,
1998) unless the signature is on file. In lieu of signing
the claim, the patient must sign a statement to be retained
in the provider, physician, or supplier’s file in accordance
with Chapter 1 "General Billing Requirements". If the
patient is physically or mentally unable to sign, a
representative specified in Chapter 1 "General Billing
Requirements" may sign on the patient’s behalf. In this
event, the statement’s signature line must indicate the
patient’s name followed by "by" the representative’s name,
address, relationship to the patient, and the reason the
patient cannot sign. The authorization is effective
indefinitely unless the patient or the patient’s
representative revokes this arrangement.
Note: This can be
"Signature on File" and/or a computer generated signature.
The patient’s signature authorizes release of medical
information necessary to process the claim. It also
authorizes payment of benefits to the provider of service or
supplier when the provider of service or supplier accepts
assignment on the claim.
Signature by Mark (X): Where an illiterate
or physically handicapped enrollee signs by mark (X), a
witness must enter his or her name and address next to the
|Item 13 (Signature):
The signature in this item authorizes payment of
mandated Medigap benefits to the participating physician or
supplier if the required Medigap information is included in
ltem 9 and its subdivisions. The patient or his or her
authorized representative signs this item, or the signature
must be on file as a separate Medigap authorization (See
Signature on File beginning on p. 3.S.1.) The Medigap
assignment on file in the participating physician/supplier's
office must be insurer specific. It may state that the
authorization applies to all occasions of service until it
Note: This can be "Signature on File" and/or a
computer generated signature.
Reminder: For date fields other than date of
birth, all fields must be one or the other format, 6-digit:
(MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two
formats on the claim is not allowed.
|Item 14 (Date of Illness):
The patient’s 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY)
date of current illness, injury, or pregnancy. For
chiropractic services, enter either a 6-digit (MM/DD/YY) or
8-digit (MM/DD/CCYY) date of the initiation of the course of
treatment and enter an 8-digit (MM/DD/CCYY) or 6-digit
(MM/DD/YY) date in item 19.
Leave blank. Not required by Medicare.
|Item 16 (Dates Patient Unable to Work):
The patient is employed and is unable to work in current
occupation, a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY)
date must be shown when patient is unable to work. An entry
in this field may indicate employment related insurance
|Item 17 (Name of Referring Physician):
Enter the name of the referring and/or ordering physician if
the service or item was ordered or referred by a physician.
A physician who requests an item or service for the
beneficiary for which payment may be made under the Medicare
A physician who orders non-physician services for the
patient, such as diagnostic laboratory tests, clinical
laboratory tests, pharmaceutical services, or durable
The ordering/referring requirement became effective
January 1, 1992, and is required by §1833(q) of the Act.
AlI claims for Medicare covered services and items that
are the result of a physician's order or referral must
include the ordering/referring physician’s name and Unique
Physician Identification Number (UPIN). This includes
parenteral and enteral nutrition, immunosuppressive drug
claims, and the following:
- Diagnostic laboratory services;
- Diagnostic radiology services;
- Portable x-ray services;
- Consultative services; and
- Durable medical equipment
Claims for other ordered/referred services not included
in the preceding list must also show the ordering/referring
physician's name and UPIN. For example, a surgeon must
complete items 17 and 17a when a physician refers the
patient. When the ordering physician is also the performing
physician (as often is the case with in-office clinical
laboratory tests), the performing physician's name and
assigned UPIN must appear in items 17 and 17a.
All physicians who order or refer Medicare beneficiaries
or services must obtain an UPIN, even though they may never
bill Medicare directly. A physician who has not been
assigned a UPIN must contact Medicare Services.
When a physician extender or other limited licensed
practitioner refers a patient for consultative service, the
name and UPIN of the physician supervising the limited
licensed practitioner must appear in items 17 and 17a of the
first claim form.
When a patient is referred to a physician who also orders
and performs a diagnostic service, a separate claim form is
required for the diagnostic service.
Enter the original ordering/referring physician's name
and UPIN in items 17 and 17a of the first claim form.
Enter the ordering (performing) physician's name and UPIN
in items 17 and 17a of the second claim form (the claim for
reimbursement for the diagnostic service).
Surrogate UPINs: If the ordering/referring physician has
not been assigned a UPIN, one of the surrogate UPINs listed
below must be used in item 17a. The surrogate UPIN used
depends on the circumstance and is used only until the
physician is assigned a UPIN. Enter the physician's name in
item 17 and the surrogate UPIN in item 17a. All surrogate
UPINs, with the exception of retired physicians (RET000) are
temporary and may be used only until a UPIN is assigned.
Medicare Services will monitor claims with surrogate UPINs.
The term "physician," when used within the meaning of
§1861(r) the Social Security Act, and used in connection
with performing any function or action, refers to:
- A doctor of medicine or osteopathy legally
authorized to practice medicine and surgery by the State
in which he/she performs such function or action;
- A doctor of dental surgery or dental medicine who is
legally authorized to practice dentistry by the State in
which he/she performs such functions, and who is acting
within the scope of his/her license when performing such
- A doctor of podiatric medicine for purposes of §(k),
(m), (p)(1) and (s) and §1814(a), 1832(a)(2)(F)(ii) and
1835 of the Act, but only with respect to functions
which he/she is legally authorized to perform as such by
the State in which he/she performs them;
- A doctor of optometry, but only with respect to the
provision of items or services described in §1861(s) of
the Act, which he/she is legally authorized to perform
as a doctor of optometry by the State in which he/she
performs them; or
A chiropractor who is licensed as such by a State (or
in a State which does not license chiropractors as such)
and is legally authorized to perform the services of a
chiropractor in the jurisdiction in which he/she
performs such services, and who meets uniform minimum
standards specified by the Secretary, but only for
purposes of §1861(s)(1) and 1861(s)(2)(A) of the Act,
and only with respect to treatment by means of manual
manipulation of the spine (to correct a subluxation).
For the purposes of §1862(a)(4) of the Act and subject
to the limitations and conditions provided above,
chiropractor includes a doctor of one of the arts
specified in the statute and legally authorized to
practice such art in the country in which the inpatient
hospital services (referred to in §1862(a)(4) of the
Act) are furnished.
|Item 17 a (UPIN or NPI of Referring
Enter the CMS assigned UPIN of the referring/ordering
physician listed in item 17. The UPIN may be reported on the
Form CMS-1500 until May 22, 2007, and MUST be reported if an
NPI is not available. NOTE: Field17a and/or 17b is
required when a service was ordered or referred by a
physician. Effective May 23, 2007, and later, 17a is not to
be reported but 17b MUST be reported when a service was
ordered or referred by a physician.When a claim involves
multiple referring and/or ordering physicians, a separate
Form CMS-1500 shall be used for each ordering/referring
physician. All physicians who order or refer Medicare
beneficiaries or services must report either an NPI or UPIN
or both prior to May 23, 2007. After that date, an NPI (but
not a UPIN) must be reported even though they may never bill
Medicare directly. A physician who has not been assigned a
UPIN shall contact the Medicare carrier.
|Item 17b Form CMS-1500 (08-05) —
Enter the NPI of the referring/ordering physician listed in
item 17 as soon as it is available. The NPI may be reported
on the Form CMS-1500 (08-05) as early as October 1, 2006.
NOTE: Field17a and/or 17b is required when a service was
ordered or referred by a physician. Effective May 23, 2007,
and later, 17a is not to be reported but 17b MUST be
reported when a service was ordered or referred by a
|Item 18 (Hospitalization Dates):
Enter either an 8-digit (MM/DD/CCYY) or a 6-digit
(MM/DD/YY) date when a medical service is furnished as a
result of, or subsequent to a related hospitalization.
Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY)
date patient was last seen and theUPIN(NPI when it becomes
effective) of his/her attending physician when an
independent physical or occupational therapist or physician
providing routine foot care submits claims. For physical and
occupational therapists, entering this information certifies
that the required physician certification (or
recertification) is being kept on file. (See Medicare
Benefits Policy Manual, Chapter 15)
Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) x-ray
date for chiropractor services (if an x-ray, rather than a
physical examination was the method used to demonstrate the
subluxation). By entering an x-ray date and the initiation
date for course of chiropractic treatment in item 14, the
contractor is certifying that all the relevant information
requirements (including level of subluxation) of the
Medicare Benefits Policy Manual, Chapter 15, are on file,
along with the appropriate x-ray and all are available for
The drug's name and dosage when submitting
a claim for Not Otherwise Classified (NOC) drugs. A concise
description of an "unlisted procedure code" or a NOC code if
one can be given within the confines of this box. Otherwise
an attachment must be submitted with the claim. All
applicable modifiers when modifier -99 (multiple modifiers)
is entered in item 24d. If modifier -99 is entered on
multiple line items of a single claim form, all applicable
modifiers for each line item containing a -99 modifier
should be listed as follows: 1=(mod), where the number 1
represents the line item and "mod" represents all modifiers
applicable to the referenced line item.
The statement "Homebound" when an independent laboratory
renders an EKG tracing or obtains a specimen from a
homebound or institutionalized patient. (See the Medicare
Benefit Policy Manual, Chapter 15, "Covered Medical and
Other Services," and the Claims Processing Manual, Chapter
16, "Laboratory Services," and the Medicare General
Information, Eligibility, and Entitlement Manual, Chapter 5,
"Definitions," respectively for the definition of
"homebound" and a more complete definition of a medically
necessary laboratory service to a homebound or an
Enter the statement, "Patient refuses to assign benefits"
when the beneficiary absolutely refuses to assign benefits
to a participating provider. In this case, no payment may be
made on the claim.
Enter the statement, "Testing for hearing aid" when
billing services involving the testing of a hearing aid(s)
is used to obtain intentional denials when other payers are
When dental examinations are billed, the specific surgery
for which the exam is being performed.
Enter the specific name and dosage amount when low
osmolar contrast material is billed, but only if HCPCS codes
do not cover them. Enter the 6-digit (MM/DD/YY) or 8-digit
(MM/DD/CCYY) assumed and/or relinquished date for a global
surgery claim when providers share post-operative care.
Enter the demonstration ID number "30" for all national
emphysema treatment trial claims.
Enter the PIN (or NPI when effective) of the
physician who is performing a purchased interpretation of a
diagnostic test (see the Medicare Claims Processing Manual,
Chapter 1, "General Billing Requirements," for additional
information). Report the interpreting physician’s PIN
proceeded by a "PI" indicator (i.e., PI999999).
Complete this item when billing for diagnostic tests
subject to purchase price limitations. The purchase price
under charges must be shown if the "yes" block is checked. A
"yes" check indicates that an entity other than the entity
billing for the service performed the diagnostic test. A
"no" check indicates that "no purchased tests are included
on the claim." When "yes" is annotated, item 32 must be
completed. When billing for purchased diagnostic tests, each
test must be submitted on a separate claim form. Multiple
purchased tests may be submitted on the ASC X12 837
electronic format as long as appropriate line level
information is submitted when services are rendered at
different facility service locations. See Chapter 1.
This is a required field when billing for diagnostic tests
subject to purchase price limitations.
Enter the patient's diagnosis/condition. With the
exception of claims submitted by ambulance suppliers
(specialty type 59), all physician and non-physician
specialties (i.e., PA, NP, CNS, CRNA) must use an ICD-9-CM
code number and code to the highest level of specificity.
Enter up to four codes in priority order (primary, secondary
condition). An independent laboratory must enter a diagnosis
only for limited coverage procedures.
diagnoses for non-physician specialties must be submitted on
Leave blank. Not required by Medicare.
Enter the Quality Improvement Organization (QIO) prior
authorization number for those procedures requiring PRO
prior approval. Enter the Investigational Device Exemption
(IDE) number when an investigational device is used in an
FDA-approved clinical trial.
For physicians performing
care plan oversight services, enter the 6-digit Medicare
provider number (or NPI when effective) of the home health
agency (HHA) or hospice when CPT code G0181 (HH) or G0182
(Hospice) is billed.
The 10-digit Clinical Laboratory Improvement Act (CLIA)
certification number for laboratory services billed by an
entity performing CLIA covered procedures.
When a physician provides services to a beneficiary
residing in a SNF and the services were rendered to a SNF
beneficiary outside of the SNF, the physician should enter
the Medicare facility provider number of the SNF in item 23.
A substituting physician under a reciprocal billing or
locum tenens arrangement (mandated by statute §1842(b)(6)(D)
of the Act) may be accommodated using item 23. The billing
"absentee" physician’s Provider Identification Number (PIN)
must continue to be reported in item 33 under solo practice
arrangements and in item 24k under group practice
Note: Item 23 can contain only one condition. Any
additional conditions must be reported on a separate CMS1500
Enter a 6-digit or 8-digit (MM/DD/CCYY) date for each
procedure, service, or supply. When "from" and "to" dates
are shown for a series of identical services, enter the
number of days or units in column G. This is a required
Note: Claim is unprocessable if a date of service
extends more than one day and a valid "to" date is not
Enter the appropriate place of service code(s) from the
list provided in §50.5. Identify the location, using a place
of service code, for each item used or service performed.
This is a required field.
Medicare providers are not required to complete this
Enter the procedures, services, or supplies using the
CMS Common Procedure Coding System (HCPCS). When applicable,
show HCPCS modifiers with the HCPCS code. The Form CMS-1500
(08-05) has the ability to capture up to four modifiers.
Enter the specific procedure code must be shown without a
narrative description. However, when reporting an "unlisted
procedure code" or a NOC code, include a narrative
description in item 19 if a coherent description can be
given within the confines of that box. Otherwise, an
attachment must be submitted with the claim. This is a
Note: Claim is unprocessable if an "unlisted procedure
code" or a "not otherwise classified" (NOC) code is
indicated in item 24d, but an accompanying narrative is not
present in Item 19 or on an attachment.
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,
the primary reference number for each service; either a 1,
or a 2, or a 3, or a 4. This is a required field. If a
situation arises where two or more diagnoses are required
for a procedure code (e.g., pap smears), the provider must
reference only one of the diagnoses in item 21.
Enter the charge for each listed service.
Enter the number of days or units. This field is most
commonly used for multiple visits, units of supplies,
anesthesia minutes, or oxygen volume. If only one service is
performed, the numeral 1 must be entered. Some services
require that the actual number or quantity billed be clearly
indicated on the claim form (e.g., multiple ostomy or
urinary supplies, medication dosages, or allergy testing
procedures). When multiple services are provided, the actual
number provided must be indicated.
For anesthesia, the
provider must indicate the elapsed time (minutes) in item
24g. Convert hours into minutes and enter the total minutes
required for this procedure.
Suppliers must furnish the units of oxygen contents
except for concentrators and initial rental claims for gas
and liquid oxygen systems. Rounding of oxygen contents is as
For stationary gas system rentals, suppliers must
indicate oxygen contents in unit multiples of 50 cubic feet
in item 24g, rounded to the nearest increment of 50. For
example, if 73 cubic feet of oxygen were delivered during
the rental month, the unit entry "01" indicating the nearest
50 cubic foot increment is entered in item 24g.
· For stationary liquid systems, units of contents must
be specified in multiples of 10 pounds of liquid contents
delivered, rounded to the nearest 10 pound increment. For
example, if 63 pounds of liquid oxygen were delivered during
the applicable rental month billed, the unit entry "06" is
entered in item 24g.
· For units of portable contents only (i.e., no
stationary gas or liquid system used), round to the nearest
five feet or one liquid pound, respectively.
Note: This field should contain at least one day or unit.
Leave blank. Not required by Medicare.
Enter the ID qualifier 1C in the shaded portion.
Prior to May 23, 2007, enter the rendering provider’s
PIN in the shaded portion. In the case of a service provided
incident to the service of a physician or non-physician
practitioner, when the person who ordered the service is not
supervising, enter the PIN of the supervisor in the shaded
portion. Effective May 23, 2007 and later, do not use the
shaded portion. Beginning no earlier than October 1, 2006,
enter the rendering provider’s NPI number in the lower
portion. In the case of a service provided incident to the
service of a physician or non-physician practitioner, when
the person who ordered the service is not supervising, enter
the NPI of the supervisor in the lower portion.
There is no Item 24K on version (08-05).
Enter the provider of service or supplier Federal Tax
I.D. (Employer Identification Number) or Social Security
Number. The participating provider of service or supplier
Federal Tax I.D. number is required for a mandated Medigap
Enter the patient's account number assigned by the
provider of service's or supplier's accounting system. This
field is optional to assist the provider in patient
identification. As a service, any account numbers entered
here will be returned to the provider.
Check the appropriate block must be checked to indicate
whether the provider of service or supplier accepts
assignment of Medicare benefits. If MEDIGAP is indicated in
block 9 and MEDIGAP payment authorization is given in item
13, the provider of service or supplier must also be a
Medicare participating provider of service or supplier and
must accept assignment of Medicare benefits for all covered
charges for all patients.
The following providers of
service/suppliers and claims can only be paid on an
- Clinical diagnostic laboratory services;
- Physician services to individuals dually entitled to
Medicare and Medicaid;
- Participating physician/supplier services,
- Services of physician assistants, nurse
practitioners, clinical nurse specialists,
- nurse midwives, certified registered nurse
anesthetists, clinical psychologists, and
- clinical social workers;
- Ambulatory surgical center services for covered ASC
- Home dialysis supplies and equipment paid under
- Ambulance services; and
- Drugs and biologicals.
Enter the total charges for the services (i.e., total of
all charges in item 24f).
Enter the total amount the patient paid on the covered
Leave blank. Not required by Medicare.
Enter the signature of the practitioner or supplier, or
his/her representative, and either the 6-digit date (MM/DD/YY),
8-digit date (MM/DD/CCYY), or alphanumeric date (e.g.,
January 1, 1998) the form was signed.
Note: This is a
required field, however, the claim can be processed if the
following is true. If a physician, supplier, or authorized
person’s signature is missing, but the signature is on file;
or if any authorization is attached to the claim or if the
signature field has "Signature on file" and/or a computer
Enter the name and address, and ZIP code of the facility
if the services were furnished in a hospital, clinic,
laboratory, or facility other than the patient's home or
physician's office. Effective for claims received on or
after April 1, 2004, the name, address, and zip code of the
service location for all services other than those furnished
in place of service home — 12. Effective for claims received
on or after April 1, 2004, on the Form CMS-1500, only one
name, address and zip code may be entered in the block. If
additional entries are needed, separate claim forms shall be
submitted. Providers of service (namely physicians) shall
identify the supplier's name, address, and ZIP code when
billing for purchased diagnostic tests. When more than one
supplier is used, a separate Form CMS-1500 should be used to
bill for each supplier. For foreign claims, only the
enrollee can file for Part B benefits rendered outside of
the United States. These claims will not include a valid ZIP
code. When a claim is received for these services on a
beneficiary submitted Form CMS-1490S, before the claim is
entered in the system, it should be determined if it is a
foreign claim. If it is a foreign claim, follow instructions
in chapter 1 for disposition of the claim. The carrier
processing the foreign claim will have to make necessary
accommodations to verify that the claim is not returned as
unprocessable due to the lack of a ZIP code. For durable
medical, orthotic, and prosthetic claims, the name and
address of the location where the order was accepted must be
entered (DMERC only). This field is required. When more than
one supplier is used, a separate Form CMS-1500 should be
used to bill for each supplier. This item is completed
whether the supplier's personnel performs the work at the
physician's office or at another location. If a modifier is
billed, indicating the service was rendered in a Health
Professional Shortage Area (HPSA) or Physician Scarcity Area
(PSA), the physical location where the service was rendered
shall be entered if other than home.
Complete this item
for all laboratory work performed outside a physician's
office. If an independent laboratory is billing, enter the
place where the test was performed.
Enter the NPI of the service facility as soon as it
is available. The NPI may be reported on the CMS-1500
(08-05) as early as October 1, 2006.
Enter the ID qualifier 1C followed by one blank space and
then the PIN of the service facility. Effective May 23,
2007, and later, 32b is not to be reported.
service (namely physicians) shall identify the supplier's
PIN when billing for purchased diagnostic tests. If the
supplier is a certified mammography screening center, enter
the 6-digit FDA approved certification number. For durable
medical, orthotic, and prosthetic claims, enter the PIN (of
the location where the order was accepted) if the name and
address was not provided in item 32 (DMERC only).
Enter the practitioner's/supplier's billing name,
address, zip code, and telephone number. Enter the UPINfor
the performing provider of service/supplier who is not
a member of a group practice. This includes the PIN of a
billing "absentee" physician in a solo practice.
billing the DMERC will use the National Supplier
Clearinghouse (NSC) number in this field.
Enter the group PIN for the performing
practitioner/supplier who is a member of a group practice.
Effective May 23, 2007, and later, you MUST enter the
NPI of the billing provider or group. The NPI may be
reported on the CMS-1500 (08-05) as early as October 1,
2006. This is a required field.
Enter the ID qualifier 1C followed by one blank space
and then the PIN of the billing provider or group. Effective
May 23, 2007, and later, 33b is not to be reported.
Suppliers billing the DMERC will use the National Supplier
Clearinghouse (NSC) number in this item. Enter the PIN for
the performing provider of service/supplier who is not
a member of a group practice. Enter the group PIN for
the performing provider of service/supplier who is a member
of a group practice. Enter the group UPIN, including the
2-digit location identifier, for the performing
practitioner/supplier who is a member of a group practice.
Please send an e-mail to
firstname.lastname@example.org with any comments
or questions you might have.