Secondary claim submission CMS 1500 requirements


Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: ( Instructions for the completion of each block of the CMS-1500 are provided in this section. See page 20 for a reproduction of a CMS-1500 showing the reference numbers of Blocks. Blocks that refer to third party payers must be completed only if there is a third party payer other than Medicare or Medicaid.

The Medical Assistance Program is by law the “payer of last resort”. If a recipient is covered by other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim.


For Medical Assistance processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

Block 1            -       Show all type(s) of health insurance applicable to this claim by checking the appropriate box(es).

Block 1a          -        INSURED’S ID NUMBER – Enter the patient’s Medicare number if applicable. The patient’s (recipient’s) 11-digit  Maryland Medical Assistance number is required in Block 9a. – Situational.

Block 2             -      PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Medical Assistance card. - Required

Block 3             -      PATIENT’S BIRTH DATE/SEX – Enter the patient’s (recipient’s) date of birth and sex. – Optional.

Block 4             -      INSURED’S NAME (Last Name, First Name, Middle Initial) – Enter the  name of the person in whose name the  third party coverage is listed, only when applicable. – Optional.

Block 5             -      PATIENT’S ADDRESS – Enter the patient’s (recipient’s) complete mailing address with zip code and telephone    number. – Optional.

Block 6               -       PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party  health insurance besides Medicare and Medicaid. – Optional.

Block 7                -          INSURED’S ADDRESS – When there is third party health insurance coverage besides Medicare and  Medicaid, enter the insured’s address and telephone number. – Optional.

Block 9a                -         OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the Patient’s (recipient’s) 11-digit Maryland   Medical Assistance number exactly as it appears on the MA card. The MA number must appear in this Block regardless of whether or  not a recipient has other insurance. Medical Assistance eligibility should    be verified on each date of service by calling EVS. EVS is operational 24 hours a day, 365 days a year at  the following number: 1-866-710-1447-Required

Block 11 INSURED’S POLICY GROUP OR FECA NUMBER – If the recipient has other third party health insurance and the claim has been rejected by that insurance, enter the appropriate rejection code  listed below: For information regarding recipient’s coverage, contact  Third Party Liability Unit at 410-767-1771. Required


                      K      Services Not Covered
                      L       Coverage Lapsed
                      M      Coverage Not in Effect on Service Date
                      N      Individual Not Covered
                      Q      Claim Not Filed Timely (Requires documentation, e.g., a copy of rejection from the insurance company.)
                      R      No Response from Carrier Within 120 Days of Claim Submission (Requires documentation e.g., a statement indicating a claim submission but no response.)
                      S  Other Rejection Reason Not Defined Above (Requires documentation, e.g., a statement on the claim indicating that payment was applied to  the deductible.)


Block 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE –  Completion is optional if a valid Medical Assistance individual practitioner identification number is entered in Block #17a. To complete, enter the full name of the ordering practitioner. Do not submit an invoice unless there is an order on file that  verifies the identity of the ordering practitioner. Required

Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services.

Block 17a (gray ID NUMBER OF REFERRING PHYSICIAN – Enter the ID Qualifier – shaded area) 1D (Medicaid Provider Number) followed by the provider’s 9-digit Medicaid Provider Number. Required

Block 17b Enter the NPI of the referring, ordering, or supervising provider listed in Block 17. Required

Block 21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY – Enter  the 3, 4, or 5 character code from the ICD-9 related to the  procedures, services, or supplies listed in Block #24d. List the primary diagnosis on Line 1 and secondary diagnosis on Line 2. Additional diagnoses are optional and may be listed on Lines 3 and 4. Required.

Block 24 A-G (gray shaded area) NATIONAL DRUG CODE (NDC) – Report the NDC/quantity when billing for drugs using the J-code HCPCS. Allow for the entry of 61 characters from the beginning of 24A to the end of 24G. Begin by entering the qualifier N4 and then the 11-digit NDC number. It may be necessary to pad NDC numbers with left-adjusted zeroes in order to report eleven digits. Without skipping a space or adding hyphens, enter the unit of measurement qualifier followed by the numeric quantity administered to the patient. Below are the measurement qualifiers when reporting NDC units: Required.

                                                        Measurement Qualifiers

                                                       F2                   International Unit
                                                      GR                   Gram
                                                       ML                  Milliliter
                                                       UN                  Units

                      Example: NDC/Quantity Reporting
                     24A DATE(S) OF SERVICE                    D. PROCEDURES, SERVICES G. DAYS OR UNITS
                     ROM:                                     TO:                                CPT/HCPCS
                     MM DD YY                             MM DD YY                               -
                     N400009737604UN1                (SHADED AREA)                         -
                     01 01 08                                   01 01 08                                  J1055

More than one NDC can be reported in the shaded lines of Box 24. Skip three spaces after the first NDC/Quantity has been reported and enter the next NDC qualifier, NDC number, unit qualifier and quantity. This may be necessary when multiple vials of the same drug are administered with different dosages and NDCs.

Block 24A DATE(S) OF SERVICE – Enter each separate date of service as a 6-digit numeric date (e.g. June 1, 2005 would be 06/01/05) under the FROM heading. Leave the space under the TO heading blank. Each date of service on which a service was rendered must be listed on a separate line. Ranges of dates are not accepted on this form. Required

Block 24B PLACE OF SERVICE – For each date of service, enter the appropriate 2- digit place of service code listed below to describe the site. Required

               Code                            Location                                code                                   Location

                       11  Office                                              42  Ambulance – Air or Water
                       12   Patient’s Residence                        50  Federally Qualified Health Ctr.
                       21  Inpatient Hospital                            51  Inpatient Psychiatric Facility
                       22  Outpatient Hospital                           52  Psychiatric Facility Partial Hospitalization
                       23  Emergency Room – Hospital                  53  Community Mental Health Ctr.
                       24  Ambulatory Surgical Ctr.                          56  Psychiatric Residential Treatment Ctr.
                       25    Birthing Ctr                                   61  Comprehensive Inpatient Rehabilitation Ctr.
                       26 Military Treatment Ctr                               62 Comprehensive Outpatient Rehab. Ctr.
                       32 Skilled Nursing Facility                             71 State or Local Public Health Clinic
                      31  Nursing Home                                         72  Rural Health Clinic
                      33  Custodial Care                                       81  Independent Laboratory
                      34  Hospice                                              99  Other Unlisted Facility

Block 24C EMG – Leave Blank.

Block 24D PROCEDURES, SERVICES OR SUPPLIES – Enter the five-character procedure code that describes the service provided and two-character modifier, if required. See pages 6-8 in Physicians’ Fee Schedule for use of modifiers. Required

Block 24E DIAGNOSIS POINTER – Enter a single or combination of diagnosis items 1, 2, 3, 4) from Block #21 above for each line on the invoice. Required

Block 24F CHARGES – Enter the usual and customary charges. Do not enter the Maryland Medicaid maximum fee unless that is your usual and customary charge. If there is more then one unit of service on a line, the charge for that line should be the total of all units. Required

Block 24G DAYS OR UNITS – Enter the total number of units of service for each procedure. The number of units must be for a single visit or day. Multiple, identical services rendered on different days should be billed on separate lines. Required

NOTE: Multiple, identical services for medical, radiological, or pathological services, within the CPT code range of 70000-89999, rendered on the same day, must be combined and entered on one line.

Block 24H EPSDT FAMILY PLAN – Leave Blank.

Block 24I ID. QUAL. – Enter the ID Qualifier 1D (Medicaid Provider Number) Required

NOTE: This two-digit qualifier identifies the non-NPI number followed by the ID number. When required to indicate the provider’s 9-digit MA provider number, the ID Qualifier 1D must precede this number.

Block 24J (gray RENDERING PROVIDER ID. # – Enter the 9-digit MA provider number shaded area) of the practitioner rendering the service. In some instances, the rendering number may be the same as the payee provider number in Block #33. Enter the rendering provider’s NPI in the unshaded area. Required

Block 25 FEDERAL TAX I.D. NUMBER – Optional.

Block 26 PATIENT’S ACCOUNT NUMBER – An alphabetic, alpha-numeric, or numeric patient account identifier (up to 13 characters) used by the provider’s office can be entered. If recipient’s MA number is incorrect, this number will be recorded on the Remittance Advice. – Optional.

Block 27 ACCEPT ASSIGNMENT? – For payment of Medicare coinsurance and/or deductibles, this Block must be checked “Yes”. Providers agree to accept Medicare and/or Medicaid assignment as a condition of participation. 

NOTE: Regulations state that providers shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any recipient for covered services.

Block 28 TOTAL CHARGE – Enter the sum of the charges shown on all lines of Block #24F of the invoice. Required

Block 29 AMOUNT PAID – Enter the amount of any collections received from any third party payer, except Medicare. If the recipient has third party insurance and the claim has been rejected, the appropriate rejection code shall be placed in Block # 11. Required

Block 30 BALANCE DUE – Optional.


NOTE: The date of submission must be entered here in order for the claim to be reimbursed.

Block 32 SERVICE FACILITY LOCATION INFORMATION – Complete only if billing for medical laboratory services referred to another laboratory, or the facility where trauma services were rendered. Enter the name and address of facility.

Block 32a NPI – Enter facility’s NPI number. Required

Block 32b (gray Enter the ID Qualifier 1D (Medicaid Provider Number) followed by the shaded area) facility’s 9-digit Maryland Medicaid provider number Required

NOTE: The Program will not pay a referring laboratory for medical laboratory services referred to a reference laboratory that is not enrolled. The referring laboratory also agrees not to bill the recipient for medical laboratory services referred to a nonparticipating reference laboratory.

Block 33 BILLING PROVIDER INFO & PH# - Enter the name, complete street address, city, state, and zip code of the provider. This should be the address to which claims may be returned. Required

Block 33a NPI - Enter the NPI number of the billing provider in Block # 33. Errors or omissions of this number will result in non-payment of claims. Required

Block 33b (gray Enter the ID Qualifier 1D (Medicaid Provider Number) followed by the shaded area) 9-digit MA provider number of the provider in Block #33. Errors or omissions of this number will result in non-payment of claims. Required

NOTE: It is the provider’s responsibility to promptly report all changes of name, pay to address, correspondence address, practice locations, tax identification number, or certification to Provider Master File at 410-767-5340.

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