Field 1 is where you indicate the type of insurance coverage your
"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 in...
Field 1a is the Insured's ID Number. This information identifies the
insured to the payer.
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 Member ...
The "Claim Codes" identify additional information about the patient's
condition or the claim.
INSTRUCTIONS: When applicable, use to report appropriate claim codes.
Applicable claim codes are designated by the NUCC. Please refer to the
most current instr...
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) under ...
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
INSTRUCTIONS: Enter the 8-digit date of birth (MM│DD│YYYY) of the
insured and an X to indicate the sex (...
The "Other Claim ID" is another identifier applicable to the claim.
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, or Wor...
The "Insurance Plan Name or Program Name" is the name of the plan or
program of the insured as indicated in Item Number 1a.
INSTRUCTIONS: Enter the name of the insurance plan or program of the
insured. Some payers require an identification number of the...
"Is there another health benefit plan" indicates that the patient has
insurance coverage other than the plan indicated in Item Number 1.
INSTRUCTIONS: When appropriate, enter an X in the correct box. If
marked "YES", complete 9, 9a, and 9d. Only one box...
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.
INSTRUCTIONS: Enter "Signature on File," "SOF," or legal s...
The "Insured's or Authorized Person's Signature" indicates that there
is a signature on file authorizing payment of medical benefits.
INSTRUCTIONS: Enter "Signature on File," "SOF," or legal signature. If
there is no signature on file, leave blank or en...
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.
INSTRUCTIONS: Enter the patient's full last name, first name, and
middle initial. If the patient uses ...
Field 3, the "Patient's Birth Date, Sex" is information that will
identify the patient and it distinguishes persons with similar names.
INSTRUCTIONS: Enter the patient's 8-digit birth date (MM | DD | YYYY).
Enter an X in the correct box to indicate sex ...
The "Insured's Name" identifies the person who holds the policy, which
would be the employee for employer-provided health insurance.
INSTRUCTIONS: Enter the insured's full last name, first name, and
middle initial. If the insured uses a last name suffix...
Field 5 - The "Patient's Address" is the patient's permanent
residence. A temporary address or school address should not be used.
INSTRUCTIONS: Enter the patient's address. The first line is for the
street address; the second line, the city and state; t...
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 insur...
The "Insured's Address" is the insured's permanent residence, which
may be different from the patient's address in Item Number 5.
INSTRUCTIONS: Enter the insured's address. If Item Number 4 is
completed, then this field should be completed. The first li...
The "Other Insured's Name" indicates that there is a holder of another
policy that may cover the patient.
INSTRUCTIONS: If Item Number 11d is marked, complete fields 9, 9a, and
9d, otherwise leave blank. When additional group health coverage
The "Other Insured's Policy or Group Number" identifies the policy or
group number for coverage of the insured as indicated in Item Number
Enter the policy or group number of the other insured.
Do not use a hyphen or space as a separator within the ...
Field 9b of the CMS 1500 form is reserved for NUCC use. Leave Blank
MEDICARE - Leave blank.
Field 9c is reserved for NUCC use. Leave blank.
MEDICARE - Leave blank if item 9d is completed. Otherwise, enter the
claims processing address of the Medigap insurer. Use an abbreviated
street address, two-letter postal code, and ZIP code copied from th...
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.
INSTRUCTIONS: Enter the other insured's insurance plan or program
MEDICARE - Enter the Coordination of Benef...
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 acciden...