Box #

Description 

1a

Required  Insured’s ID number will be the full 12 digit claim number of the injured worker. “NOTE:  the claim number may be entered anywhere on the CMS 1500 form to be accepted”.

2

Required  Injured Employee’s name

3

Required  Injured employee’s date of birth/sex

5

Required  Injured employee’s address

10

Required  “Is patient’s condition related to…?

11

Claim number may also be entered here

12

The patient (injured employee) or authorized representative must sign/date the form unless there is a signature on file, then “Signature on file” is sufficient

14

Required  Accident/Injury Date

17a

Referring Provider Taxonomy (if applicable) – input ZZ in first box and 10-character taxonomy code without spaces in the second box

17b

Referring provider NPI# (if applicable), input 10-character NPI number

21

Required  ICD-9 diagnosis code(s) Note:  for Vocational Rehabilitation, this box is optional; enter 959.9 for voc rehab bills.

24A

Required  Date(s) of service

24B

Required  Place of service code (this field is optional for Voc Rehab, MSF PPO contracted home health, and MCM services and other MSF PPO contracted vendors or on non CMS 1500 bills).

24D

Required  Procedures, Services or Supplies – enter appropriate CPT, HCPCS or contracted code(s).  If using an unlisted code etc, also enter description.

24E

ICD-9 code or number from Box 21

24F

Required  Service charge/fee billed for each line item/code

24G

Required  # Days or unit(s) – enter the number of units for each line item/code

24I

ID Qualifier – ‘Blank’ and preprinted ‘NPI’ spaces.  Blank space should be populated with ZZ for taxonomy code listed in 24J.

24J

Required – if applicable (some exceptions would be Vocational Rehabilitation; ambulance, ambulatory surgery centers, labs, MRI centers and MCM etc)  Rendering provider ID# - If top space is ‘blank’, 24I is populated with ZZ then enter 10-digit taxonomy code in 24J (top space) note:  MSF# no longer valid.  Bottom line, enter the NPI number in the corresponding space after preprinted ‘NPI’ in 24I.

25

Required  Federal Tax ID number – enter the tax ID or SS# of the billing entity

28

Required Total Charges

31

Signature of Physician or supplier, including degrees or credentials

32

Required – if applicable (exceptions would be Ambulance, POS 12,DME and Voc Rehab). Name and address of facility where services were rendered (cannot be PO Box)

32a

Required – if applicable  (exceptions would be Ambulance, POS 12,MCM and Voc Rehab). Service Facility Location NPI – enter 10-character NPI number

32b

Service Facility Location Taxonomy – input ZZ and 10-character taxonomy code without spaces

33

Required  Physician’s, suppliers billing name, address, and zip code.

33a

Required  - if applicable (exceptions would be Ambulance, POS 12, MCMand Voc Rehab). Billing Provider NPI # - input 10-character NPI number

33b

Billing Provider Taxonomy – input ZZ and 10-character taxonomy code without spaces

Form Locator

Description

1

Required  Billing provider name, and physical address.

2

Required – if applicable  Pay to address if different than field 1.

4

Required  Type of bill –enter the three or 4 digit code that indicates the type of bill you are submitting.

5

Required  Federal Tax Number

6

Required  Statement covers period – enter the beginning and ending service date(s) of the period covered by the bill.

8

Required  Patient name – enter last name, first name and middle initial.

9a-d

Required  Patient address

10

Required  Date of birth

11

Required  Sex (“M” for male, “F” for female or “U” for unknown.

12

Admission/start of care date – enter the date the member was admitted for inpatient care, or the date of the outpatient service.

13

Admission hour – situational.  Enter the two-digit hour during which the patient was admitted for inpatient care.

14

Admission Type – enter the code indicating the priority of this admission/visit.

15

Source of Admission – enter the appropriate source of admission code

16

Discharge hour – enter the code that indicates the discharge hour of the member from inpatient care.

17

Patient discharge status – enter the appropriate patient discharge status code

42

Required  Revenue code(s) – enter the 4 digit Revenue code beside each service described in column 43.

43

Required  Description – enter a brief description that corresponds to the revenue code in column 42.

44

Required  HCPCS/Rates – for outpatient services, enter the CPT/HCPCS code.  On inpatient bills, enter the accommodation rate

45

Required  for Out Patient Claims -  Service date – enter the date on which each service was rendered.

46

Required  Units of service

47

Required  Total Charges – the sum of the total charges for the billing period for each revenue code (FL42)

Line 23

Required  Total Charges – Enter the claim total.

56

Required  Billing Provider NPI – input 10-characer NPI number.

57

Billing Provider Taxonomy – input ZZ and 10-character taxonomy code without spaces

58

Required  Insured’s name

60

Required  May enter the patient's claim number here

67A-Q

Required  Principal diagnosis code and present on admission and any other diagnosis

69

Admitting Diagnosis

74

Required  - if applicable  Principal procedure code – situational. 

76

Required  Attending Provider NPI – input 10-character NPI number

77

Operating Provider NPI – input 10-character NPI number

78-79

Other Provider’s NPI – input 10-character NPI number

81a

Billing Provider Taxonomy – input B3 in the first box and 10-character taxonomy code without spaces in second box.   

Box 3

Required Primary payer informatio; Include injured worker's complete 12 digit claim number (may also put this in Box 15)

Box 4-11

Other coverage – leave blank if no other coverage

Box 17

Employer Name

Box 20

Required  Name and address of injured employee

Box 21

Required  Injured employee date of birth

Box 22

Required  Injured employee gender

Box 24

Required  Procedure date of service

Box 27

Required Tooth number – enter tooth number or range of teeth using a hyphen

Box 28

Designate tooth surface(s)

Box 29

Required  Procedure code – enter the appropriate dental code

Box 30

Required  Description of procedure

Box 31

Required  Fee – enter corresponding fee for each procedure listed in column 29

Box 33

Required  Total fees

Box 48

Required  Billing entity name and address

Box 49

Required  Billing provider NPI – input 10-character NPI number.  If not present, the bill will be denied for this omission.

Box 51

Required  Federal tax identification number

Box 53

Required  Rendering dentist’s signature

Box 54

Required  Rendering dentist NPI – input 10-character NPI number

Box 56

Required  Rendering dentist address, city and zip code

Box 57

Rendering dentist phone number - not required