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Knowledgebase : How to Fill Out The CMS-1500 Form > The CMS-1500 Form - Fields 1–13: Patient and Insured Information

Field 1 is where you indicate the type of insurance coverage your patient has.

“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 insurance including HMOs, commercial insurance, automobile accident, liability, or workers’ compensation. This information directs the claim to the correct program and may establish primary liability.

INSTRUCTIONS: Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked.

MEDICARE  Shows the type of health insurance coverage applicable to this claim by the appropriately checked box; check the Medicare box.

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 Identification Number assigned by the payer, then enter that number in this field.

FOR TRICARE: Enter the DoD Benefits Number (DBN 11-digit number) from the back of the ID card.

FOR WORKERS COMPENSATION CLAIMS: Enter the appropriate identifier of the employee.

FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the appropriate identifier of the insured person or entity.

MEDICARE - Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer. This is a required field.

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 instructions from the public or private payer regarding the need to report claim codes.

When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field. The Condition Codes approved for use on the 1500 Claim Form are available at www.nucc.org under Code Sets.

When reporting more than one code, enter three blank spaces and then the next code.

FOR WORKERS COMPENSATION CLAIMS: Condition Codes are required when submitting a bill that is a duplicate or an appeal. (Original Reference Number must be entered in Box 22 for these situations). Note: Do not use Condition Codes when submitting a revised or corrected bill.

MEDICARE - Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD.

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 the Federal Employees Compensation Act 5 USC 8101.

INSTRUCTIONS: Enter the insured’s policy or group number as it appears on the insured’s health care identification card. If Item Number 4 is completed, then this field should be completed.

MEDICARE - THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.

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 completed.

NOTE: Enter the appropriate information in item 11c 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.

If a lab has collected previously and retained Medicare Secondary Payer (MSP) information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the
lab will enter the word “None” in Block 11, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:

  • Group Health Plan Coverage
    • Working Aged;
    • Disability (Large Group Health Plan); and
    • End Stage Renal Disease;
  • No Fault and/or Other Liability; and
  • Work-Related Illness/Injury:
    • Workers' Compensation;
    • Black Lung; and
    • Veterans Benefits.

NOTE: For a paper claim to be considered for MSP benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.

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 Number 1a.

INSTRUCTIONS: Enter the 8-digit date of birth (MM│DD│YYYY) of the insured and an X to indicate the sex (gender) of the insured. Only one box can be marked. If gender is unknown, leave blank.

MEDICARE - Enter the insured's 8-digit birth date (MM | DD | CCYY) and sex if different from item 3.

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 Workers’ Compensation insurers and related entities, the following qualifier and accompanying identifier has been designated for use:

Y4 Agency Claim Number (Property Casualty Claim Number)

Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of the vertical, dotted line.

FOR WORKERS’ COMPENSATION OR PROPERTY & CASUALTY: Required if known. Enter the claim number assigned by the payer.

MEDICARE - Form version 08/05: 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."

Form version 02/12: provide this information to the right of the vertical dotted line.

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 primary insurer rather than the name in this field.

MEDICARE - Enter 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 item 11.

“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 can be marked.

MEDICARE - Leave blank. Not required by Medicare.

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 signature. When legal signature, enter date signed in 6-digit (MM|DD|YY) or 8-digit format (MM|DD|YYYY) format. If there is no signature on file, leave blank or enter “No Signature on File.”

MEDICARE - The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier 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, 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, 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) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

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 enter “No Signature on File.”

MEDICARE - The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream coordination of benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

In addition, the signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

NOTE: This can be "Signature on File" signature and/or a computer generated signature.

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 a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.


Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.


If the patient’s name is the same as the insured’s name (i.e., the patient is the insured), then it is not necessary to report the patient’s name.

MEDICARE - Enter the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card. This is a required field.

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 (gender) of the patient. Only one box can be marked. If sex is unknown, leave blank.

MEDICARE - Enter the patient's 8-digit birth date (MM | DD | CCYY) and 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 (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

FOR WORKERS COMPENSATION CLAIMS: Enter the name of the Employer.

FOR OTHER PROPERTY & CASUALTY CLAIMS: Enter the name of the insured person or entity.

MEDICARE - If there is insurance primary to Medicare, either through the patient's 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.

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; the third line, the ZIP code.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

If the patient’s address is the same as the insured’s address, then it is not necessary to report the patient’s address.

“Patient’s Telephone” does not exist in 5010A1. The NUCC recommends that the phone number not be reported. Phone extensions are not supported.

FOR WORKERS’ COMPENSATION AND OTHER PROPERTY AND CASUALTY CLAIMS: If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

MEDICARE - 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.

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 insured’s plan. “Child” would indicate that the patient is the minor dependent, as defined by the insured’s plan. “Other” would indicate that the patient is other than the self, spouse, or child, which may include employee, ward, or dependent, as defined by the insured’s plan.

INSTRUCTIONS: Enter an X in the correct box to indicate the patient’s relationship to insured when Item Number 4 is completed. Only one box can be marked.

If the patient is a dependent, but has a unique Member Identification Number and the payer requires the identification number be reported on the claim, then report “Self”, since the patient is reported as the insured.

MEDICARE - Check the appropriate box for patient's relationship to insured when item 4 is completed.

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 line is for the street address; the second line, the city and state; the third line, the ZIP code.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

“Insured’s Telephone” does not exist in 5010A1. The NUCC recommends that the phone number not be reported. Phone extensions are not supported.

FOR WORKERS COMPENSATION CLAIMS: Enter the address of the Employer.

FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the address of the insured noted in Item Number 4.

FOR WORKERS’ COMPENSATION AND OTHER PROPERTY AND CASUALTY CLAIMS: If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

MEDICARE - 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, 6, and 11 are completed.

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 exists, enter other insured’s full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in Item Number 2. If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

MEDICARE - 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. This field may be used in the future for supplemental insurance plans.

NOTE: Only participating physicians and suppliers are to complete item 9 and its subdivisions 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 transfer. (See chapter 28.)

Medigap - 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 former members.

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 the A/B MAC (B) or DME MAC to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.

The “Other Insured’s Policy or Group Number” identifies the policy or group number for coverage of the insured as indicated in Item Number 9.

Enter the policy or group number of the other insured.

Do not use a hyphen or space as a separator within the policy or group number.

MEDICARE - Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.

NOTE: Item 9d must be completed, even when the provider enters a policy and/or group number in item 9a.

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 the Medigap insured's Medigap identification card. For example:

1257 Anywhere Street
Baltimore, MD 21204

is shown as "1257 Anywhere St. MD 21204."

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 name.

MEDICARE - Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID). 

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 accident” would indicate that the condition is the result of an automobile accident. “Other accident” would indicate that the condition is the result of any other type of accident.

INSTRUCTIONS: When appropriate, enter an X in the correct box to indicate whether one or more of the services described in Item Number 24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked.

The state postal code where the accident occurred must be reported if “YES” is marked in 10b for “Auto Accident.” Any item marked “YES” indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Item Number 11.

MEDICARE - 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. Enter the State postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.