The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs. Most institution-based services claims are submitted using a UB-04 form. Provider agreements and billing guidelines provide additional instruction for claims completion. If you wish to explore outsourcing claims and billing see factors to consider when selecting a professional billing service.
Before You Submit A Claim
Payment of claims for MNT provided in the outpatient environment is dependent on several factors, including an individual's benefits for MNT for their condition or reason (e.g., prevention), approved settings, and the network status of the RDN (or practice) with the client/patient's payer. Claims can be submitted to payers electronically through many vehicles, including practice management systems, provider portals, and claims clearinghouses. There may be some instances where paper claims are still used.
Completing a CMS 1500 Claim Form
Specific client and provider information must be provided on a CMS 1500 health insurance claim form for a payer to process a claim regardless of how it is submitted. Some payers may require additional information or require the completion of specific fields in certain situations (e.g., group number, prior authorization reference number, workers compensation). The information provided here to assist RDNs in the process of completing a claim form is general. Refer to each payer's billing instructions for more information or contact a Provider Services representative of the health plan to understand options for submitting claims.
Refer to the following sample completed claim and quick reference to assist you in completing a CMS 1500.
- Completed a CMS 1500 Form (simple example)
- CMS Quick Reference
Secondary Insurance with Medicare beneficiaries and the use of Modifiers in Claims
Some Medicare beneficiaries have secondary insurance policies (e.g., commercial insurance through work or a partner's policy) that provide benefits and coverage for conditions beyond the standard Medicare Part B MNT benefit (e.g., DM, CKD and 3 years post kidney transplant). The secondary payer may require evidence of a denied claim from the primary insurance (Medicare) before it will pay the claim (e.g., MNT for a gastroenterological or other diagnosis). A claim is submitted to Medicare that must include a modifier (GA, GZ or GY) to generate a denial required before the secondary insurance will review the claim. For more information, including descriptions and use of each modifier, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market or to page 8 of the CMS Manual.
Electronic Claims
When completing claims electronically (e.g., use of a clearinghouse) you will also select a payer ID, a unique code for each payer. Some payers may require providers to complete an agreement before they will accept electronic claims through a third-party service such as a claims clearinghouse. Otherwise, claims clearinghouses allow you to select participating payers from a menu.
Medicare electronic claims transactions must meet Electronic Data Interchange requirements. RDN Medicare providers can submit claims using applications that meet Medicare's EDI requirements. Providers must complete an EDI enrollment agreement. Registered dietitian nutritionists are able to submit claims electronically to a Medicare Administrative Contractor (MAC). Registered dietitian nutritionists should contact their MACs for more information.
For more comprehensive instructions regarding claims submission, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market.
Additional Resources
CMS-1500 Paper Claim Form
The form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS-1500 claim form may be purchased from local printers, office supply stores, or through the U.S. Government Printing Office:
U.S. Government Printing Office Superintendent of Documents Washington, DC 20402 Pricing Desk: 202/512-1800 or 866/512-1800 Fax: 202/512-2104
Email:
bookstore.gpo.gov
For healthcare professionals and medical billing companies, having a complete understanding on CMS 1500 & UB-04 forms, are extremely necessary to make their billing practice successful. These forms are designed and maintained by National Uniform Claim Committee (NUCC). CMS 1500 & UB-04 are used especially for revenue payments, and they vary in terms of usage.
Before filing a claim, it’s important to know which form to use in order to get proper reimbursement. CMS-1500 & UB-04 are the most common claim forms submitted to the insurance companies. Though they are very frequently used, both have their own specifications that allows medical billing process to run without any confusion.
Let’s get into the details to learn more about CMS 1500 & UB-04 forms.
What are CMS 1500 & UB-04 Forms?
CMS 1500:
- This form is also referred to as HCFA or the 1500 that was developed by NUCC-National Uniform Claim Committee as the standard form for healthcare professionals, individual doctors, nurses and other medical practices.
- The Centers for Medicaid and Medicare Services state that “the CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers when a provider qualifies for a waiver from the Administrative Simplification Compliance Act requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies.”
- CMS 1500 is used to bill the services of the healthcare professional performed in the hospital or the Ambulatory Surgical Center.
- This form will not be used for billing the facility services even though services are rendered by the same provider.
- CMS 1500 & UB-04 forms stand unique in their own way of billing the procedures or the services rendered by healthcare professionals.
- Unless and until these two forms are submitted, the claim process does not become complete.
UB-04:
- UB-04 form was a replacement for UB-92 in the year 2005. This form has been a standardized one from last 15+ years and is predominantly used by hospitals, ambulatory surgery centers, nursing facilities, and other medical and mental health institutions.
- The specialty of UB-04 is that, it can be submitted both electronically and in paper format.
- Insurance companies hold on to their filing methods for accepting these forms electronically or on paper. These forms are not stable for all the states. They differ accordingly.
- The only exception to is while billing facilities to Medicare. Medicare accepts only CMS 1500 and claims must be submitted in these forms.
- In UB-04, UB stands for Uniform Billing and also referred to as CMS 1450. The UB-04 form was developed by the Centers for Medicare and Medicaid Services with an intention to make the claim filing process uniform and streamlined.
What are the differences between CMS 1500 & UB-04 Forms?
- Even though UB-04 is based from CMS 1500 form, they both have drastic variations in usage.
- The hospitals don’t use CMS 1500, as they may not charge for the procedures. But healthcare professionals or physicians use this form to get their payments done on time.
- So, CMS 1500 is used only by the physicians and not hospitals. Whereas UB-04 or CMS 1450 form is used by hospitals with 81 field locators to enter all the required details like HCPCS codes, NPI, Tax ID, etc.
Structure of CMS 1500 & UB-04 claim forms:
- UB-04 claim form contains 81 locators or fields known as FL.
- These fields are used to fill specific information like the details provided below:
- Provider’s name, address and telephone number (field 1)
Patient control number (field 3a)
• Type of bill code (field 4)
• Provider’s federal tax ID number (field 5)
• Statement period (beginning and ending date of claim period) (field 6)
• Patient’s name (field 8)
• Patient’s address (field 9)
• Patient’s Date of Birth (field 10)
• Patient’s gender (field 11)
• Date of admission (field 12), required for inpatient and home health.
• Admission hour (field 13)
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14), required for inpatient.
• Source of admission code (field 15)
• Patient-status-at-discharge code (field 17)
• Value code and amounts (fields 39-41)
• Revenue code (field 42)
• Revenue & service description (field 43)
• HCPCS & Rates (current CPT or HCPCS codes) (field 44)
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required)
• Units of service (field 46)
• Total charge (field 47)
• HMO or preferred provider carrier name (field 50)
• Main NPI number (field 56)
• Subscriber’s name (field 58)
• Patient’s relationship to subscriber (field 59)
• Insured’s unique ID (field 60)
• Diagnosis qualifier (field 66)
• Principal diagnosis code (ICD-10 codes are required) (field 67)
• Admit diagnosis (field 69)
• Provider name and identifiers (field 76-79).
- The CMS 1500 claim form has 33 fields to fill the necessary details information. The fields will be as mentioned below:
- Subscriber’s or patient’s plan ID number (field 1a)
Patient’s name (field 2)
• Patient’s date of birth and gender (field 3)
• Subscriber’s name (field 4)
• Patient’s address (street or P.O. Box, city, zip) (field 5)
• Patient’s relationship to subscriber (field 6)
• Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7)
• Whether patient’s condition is related to employment, auto accident, or other accident (field 10)
• Subscriber’s policy number (field 11)
• Subscriber’s birth date and gender (field 11a)
• HMO or preferred provider carrier name (field 11c)
• Disclosure of any other health benefit plans (field 11d)
• Patient’s signature or notation that the signature is on file with the physician or provider (field 12)
• Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 13)
• Date of current illness, injury, or pregnancy (field 14)
• First date of previous, same or similar illness (field 15)
• Name of referring provider or other source (field 17)
• Referring provider NPI number (field 17b)
• Diagnosis codes or nature of illness or injury (field 21)
• Date of service (field 24A)
• Place of service codes (field 24B)
• EMG – emergency indicator (field 24C)
• Procedure/modifier code – current CPT or HCPCS codes (field 24D)
• DX Pointer – diagnosis code – ICD-10 codes are required for specific service (field 24E)
• Charge for each listed service (field 24F)
• Number of days or units (field 24G)
• Rendering provider NPI (field 24J)
• Physician’s or provider’s federal taxpayer ID number (field 25)
• Total charge (field 28)
• Signature of physician that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31)
• Name and address of facility where services were rendered (if other than home or office) (field 32)
• The service facility Type 1 NPI (if different from main or billing NPI) (field 32a)
• Physician’s or provider’s billing name and address (field 33) and
• Main or billing Type 1 NPI number (field 33a).
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