Back to Basics: Medical Claim Form
October 2024
What is a CMS 1500 Medical Claim Form?
Administered by the National Uniform Claim Committee (NUCC), the CMS 1500 medical claim form is used to request reimbursement by insurance plans for medical services rendered. It serves as a detailed record of the treatments provided and includes general information on: patient, subscriber, insurance, provider, treatment, billing entity and location. For more information, visit https://www.nucc.org/. There are also many helpful resources and companion guides available at https://www.cms.gov/medicare/coding-billing/electronic-billing.
Paper vs. Electronic
It’s easy to think that the “print preview” version of your medical claim form is what is sent electronically to your clearinghouse. However, electronic claims have their own dedicated format called the Health Care Claim Professional (837P). It is comprised of data ‘loops’ and while it is similar to the print format, it is not identical. There is a NUCC Claim for “crosswalk” that further details print fields and their counterpart data loops.
What information is included?
The CMS-1500 claim form includes general information on: patient, subscriber, insurance, provider, treatment rendered, medical diagnosis, billing entity and location type. There are currently 33 fields many that contain multiple parts. To accurately complete a claim form, it is imperative that you understand what information belongs in each field and, moreover, how your software populates it. Often there are software settings that allow you to modify or select what software fields populate in what areas of the claim form (sometimes differing for print or electronic as mentioned above). Here are a few examples:
OTHER INSURANCE – Field 9, 9A / Loop 2330A – enter patient’s other insurance coverage information with that policy’s subscriber name and insured group or policy number. Completing this section is essential when coordination of benefits relies on accurately notifying one payer about other potential insurance benefits.
RESUBMISSION – Field 22 / Loop 2300 – to submit a corrected claim, thereby revising data from a previously submitted claim already on file, enter an appropriate frequency code and cite the claim number as the original reference number.
TOTAL CHARGE – Field 28 / Loop 2300 – enter the total claim charge amount. If there are multiple print pages it is important to enter the total charge for the entire claim rather than the page total to prevent separate claims by the payer. Alternatively, you can use “continued” in this field with only the last page reflecting the total claim charge amount.
How do you know what information is required?
Requirements for services rendered vary by procedure code, clinical diagnosis, and insurance payer guidelines. It is important to stay up-to-date with annual ICD-10, CDT, and CPT coding and form updates. It is also important to stay current with all of your in-network payer specific guidelines. Sending all required information with your initial claim submission helps minimize needless rejections and denials which can delay the timely filing of your claim.
Need help, advice, or staff training?
Dental Billing & Consulting Professionals is always happy and available to be a resource to you. Our consulting and billing services are customized to your specific needs and goals. Call or text us at (860) 435-7344 any time to learn how we can support you in optimizing your practice.