CMS-1500 Claim Form Instructions
Box by box description and Therabill mapping of the CMS-1500 Claim Form.
- CMS-1500 Claim Form
- Box 1 - Plan Type
- Box 1a - Insured's I.D. Number
- Box 2 - Patient's Name
- Box 3 - Patient's Birth Date, Sex
- Box 4 - Insured's Name
- Box 5 - Patient's Address (multiple fields)
- Box 6 - Patient Relationship to Insured
- Box 7 - Insured's Address (multiple fields)
- Box 8 - Reserved for NUCC Use
- Box 9 - Other Insured's Name
- Box 9a - Other Insured’s Policy or Group Number
- Box 9b - Reserved for NUCC Use
- Box 9c - Reserved for NUCC Use
- Box 9d - Insurance Plan Name or Program Name
- Box 10a, 10b, & 10c - Is Patients Condition Related To:
- Box 10d - Claim Codes
- Box 11 - Insured's Policy, Group, or FECA Number
- Box 11a - Insured's Date of Birth, Sex
- Box 11b - Other Claim ID
- Box 11c - Insurance Plan Name or Program Name
- Box 11d - Is there another Health Benefit Plan?
- Box 12 - Patient's or Authorized Person's Signature
- Box 13 - Insured's or Authorized Person's Signature
- Box 14 - Date of Current Illness, Injury or Pregnancy
- Box 15 - Other Date
- Box 16 - Dates Patient Unable to Work in Current Occupation
- Box 17 - Name of Referring Provider or Other Source
- Box 17a - Other ID#
- Box 17b - NPI #