Essential Requirements for Completing a CMS 1500 Claim Form


Basic requirement for complete claim - CMS 1500

Complete claims requirements

• Member’s name

• Member’s address

• Member’s gender

• Member’s date of birth (dd/mm/yyyy)

• Member’s relationship to subscriber

• Subscriber’s name (enter exactly as it appears on the member’s health care ID card)

• Subscriber’s ID number

• Subscriber’s employer group name

• Subscriber’s employer group number

• Rendering Physician, Health Care Professional, or Facility Name

• Rendering Physician, Health Care Professional, or Facility Representative’s Signature

• Address where service was rendered

• Physician, Health Care Professional, or Facility “remit to” address

 • Phone number of the Physician, Health Care Professional or Facility where the service was performed. (please provide here)

 in a manner consistent with the way that information is provided in your contract with us 

• Physician’s, Health Care Professional’s, or Facility’s National Provider Identifier (NPI) and federal Tax Identification

Number (TIN)

• Referring physician’s name and TIN (if applicable)

• Date of service(s)

• Place of service(s) (for more information see:

• Number of services (day/units) rendered

• Current CPT-4 and HCPCS procedure codes, with modifiers where appropriate

 • Specific ICD-9-CM (or its successor) diagnostic code to the highest level of specificity (it is important to communicate the primary diagnosis for the service provided, especially if specific to a line item you are billing) 

• Charges per service and total charges

• Detailed information about other insurance coverage

• Information regarding job-related, auto or accident information, if available

• Retail purchase cost or a cumulative retail rental cost for DME greater than $1,000

 • NDC (National Drug Code) is the 11-digit number to use on all claim forms that you submit when there is a drug code on a claim. When the NDC number is entered, you must enter the NDC when it is required by use or refer to the LIN03 segment as part of the HIPAA 837 Professional electronic form or Claim 24D field on the CMS-1500 Form.