Free CMS-1500 Paper Claim Checklist

Privacy: The checkboxes work entirely in your browser. This page does not submit or store claim information.

Before entering the claim

Confirm that the payer accepts a paper CMS-1500 claim for this situation. Confirm the payer’s current paper-claim mailing address and timely-filing deadline. Use the current CMS-1500 (02/12) form stock required by the payer. Have the patient’s insurance card, provider information, service documentation, and any required authorization available.

Patient and insured information

Patient and insured names match the insurance card and payer records. Member or insured identification number is complete and entered in the correct field. Patient date of birth, sex, address, and relationship to the insured are reviewed. Other insurance or coordination-of-benefits information is included when applicable.

Claim and provider information

Dates related to illness, injury, pregnancy, hospitalization, or prior treatment are entered when applicable. Referring, ordering, supervising, rendering, service-facility, and billing provider information is completed when required. NPI numbers are entered in the correct locations and match the provider or organization shown. Taxonomy, legacy identifiers, claim codes, or prior authorization numbers are included only when required by the payer.

Diagnosis and service lines

Diagnosis codes are current, supported by the record, and entered without an unnecessary decimal when the form instructions require that format. Diagnosis pointers in Box 24E correctly link each service line to the diagnoses in Box 21. Dates of service, Place of Service, CPT/HCPCS codes, modifiers, charges, units, and rendering provider information are reviewed. Total charges, amount paid, and balance information are consistent with the service lines.

Printing and submission

Claim data prints inside the intended boxes and does not touch form lines or labels. Black print is clear, dark, and readable; the form is not skewed, reduced, enlarged, or clipped. Required attachments or supporting documents are included and identified as the payer directs. A copy of the submitted claim and attachments is retained, along with the mailing date or tracking information.

Important: This is a general preparation checklist, not payer-specific billing advice. Follow the current NUCC instructions and the payer’s requirements.

Official references

NUCC 1500 Instruction Manual · CMS-1500 Form Page · NPI Registry · CMS Place of Service Codes

Free CMS-1500 paper claim checklist

Before entering the claim

Patient and insured information

Claim and provider information

Diagnosis and service lines

Printing and submission

Official references

Use these resources with CMS-1500 Software