Line by line instructions for
filling out the HCFA 1500 form:
Note there
currently is a new form that is the standard - The CMS 1500
which is very similar but includes sections for NPI numbers.
Line 1. Other (usually)
Line 1a. This is the ID number of
the insured person, which is sometimes different from the client. It is usually
the social security number, but that is now changing due to HIPAA requirements.
It also could be a claim number in a MVA.
Line 2. Patient’s name
Line 3. Patient’s birth date:
Male or Female
Line 4. Insured’s name, Employer
or whoever has the insurance policy , which may be different than the
client:
possibly a spouse or parent.
Line 5. Patient’s address.
Line 6. Patient’s relationship to
insured.
Line 7. Insured’s address : if
same as patient put same.
Line 8. Patient’s status
Line 9 –9d Other insurance- if
they have a secondary insurance that may kick in later. This could be a regular
health insurance policy that may be billed for a MVA after funds are depleted or
some other secondary insurance.
Line 10. What is patient’s
condition related to? Employment, auto accident or other. If you are billing a
PPO for an Auto accident, be sure to check appropriate box.
Line 11a. Insured’s Policy Number
or Claim Number.
Line 11b. Employer or School
Line 11c. Insurance Plan name or
program
Line 12, 13. Have the client sign
a release of records statement on their intake form and keep the form on file.
Fill this in with “on file”. There may be states where you can’t do this.
Line 14. Date of Injury or
accident
Line 15. If applicable
Line 16. Provided by doctor
Line 17. Name of referring
physician
Line 17a. ID number of referring
physician (usually not needed)
Line 18. Leave blank
Line 19. Leave blank
Line 20. Leave blank
Line 21. Diagnosis Code. ICD-9
code. YOU MUST HAVE THIS! This number is provided by the physician. Even
if they just put back pain, make the doctors give you the diagnosis code, even
if you know what the code for back pain is.
Line 23. Leave blank or put
referral number from HMO or PPO.
Line 24A. Dates of Service- one
date per line. From and to are the same date.
Line 24B. Place of Service. Ask
the insurance
codes they
use. Every billing manual I have read says something different. It is usually a
3 , 11 or OF.
Line 24C. Type of Service. Ask
the insurance company what you should use. It is usually a 9 for ancillary
services.
Line 24D. CPT code goes here.
Make sure you use the right CPT code for the procedure you are performing. Some
companies will only pay for certain codes. See more on codes.
Line 24E. Diagnosis Code –
Indicate which code from line 21 you are treating for.
Line 23F. Charges for Service-
Total Charges
Line 24G. Days or Units – codes
are usually designating 15 minutes of treatment so one hour would be 4 units.
Line 24 H-K. Leave Blank
Line 25. Your federal ID Number
or SS#.
Line 26. Your patients account
number
Line 27. Leave Blank
Line 28. Total Charges for all
days
Line 29. Enter amount of co-pay
or other payment or leave blank
Line 30. Balance Due
Line 31. Your signature
Line 32. Leave blank unless you
provided service somewhere else besides your office which may or may not be
legal.
Line 33. Your name, address,
provider number
