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 Physician, Health Care Professional, or Facility performing the service (provide this information
in a manner consistent with how that information is presented in your agreement 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
• Current ICD -9-CM (or its successor) diagnostic codes by specific service code to the highest level of specificity (it is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item)
• 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
• Current NDC (National Drug Code) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPAA 837 Professional electronic form.