CMS 1500 Filing Guide: Hospital Date, EPSDT, and Patient Amount


CMS 1500 Filling Guideline for Hospital date, EPSDT, and patient amount

The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for
medical services. The form is used by Physicians and Allied Health Professionals to submit
claims for medical services. All items must be completed unless otherwise noted in these

instructions. A CMS 1500 with field descriptions and instructions is included in the link below:

Box 18 If Applicable Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge e blank.dat

Box 20 If Applicable Outside Lab? - Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory.

Box 24H If Applicable EPSDT Family Plan - Enter code “1” or “2” if the services rendered are related to family planning (FP). Enter code “3” if the services rendered are Child Health and Disability Prevention (CHDP) screening related

Box 26 optional Patient's Account Number -Enter the patient’s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated

Box 29 If Applicable Amount Paid - Enter the amount of payment received from the Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals.

Box 30 If Applicable Balance Due - Enter the difference between the Total Charges and the Amount Paid in full dollar amount and cents. Do not enter decimals.