top of page

What is a CMS 1500 Form?


Main Points:

  • What is a CMS 1500 Form

  • What do all the boxes mean


In the United States Healthcare system there are actually two types of claim forms. There is a CMS 1500 form and a UB-04 form. The claim form system was developed to help identify the procedures being performed on patients and who was performing them, however, this is a difference between hospital services and professional outpatient services. This is why there are two kinds of claim forms.

A CMS 1500 form is the claim form that mental health services are billed on and paid. They are a pink form with lots of boxes. Here is a list of those and what you should fill in or omit:

  • Boxes 1-3 and 5: This is pretty straightforward demographic information on your client. In box 1a you put the cient’s ID# that is printed on their insurance card.

  • Box 4: Put your client’s name in again. Or, if they have insurance through a parent or a spouse, enter their name instead.

  • Box 6: Indicate the relationship to the insured (if the client’s insurance is through a spouse or parent, for example) or mark “self” if they have insurance in their own name.

  • Box 7: Indicate the client’s address or if the insurance is through someone else (the “insured”), write down their address and phone number.

  • Box 8: Leave blank.

  • Box 9: This is only used if the client has multiple insurances (typically a primary and secondary). This could be a whole other blog post, so billing multiple insurances will not be covered here.

  • Box 10: The answers to these questions are all typically “no.”

  • Box 11: Enter the Insurance group # (found on the ID card).

  • Box 11a: Enter the client’s DOB, or if the insurance is through someone else, enter their birthdate.

  • Box 11b-c: Leave blank.

  • Box 11d: If they only have one insurance check “no.” If they have two insurances check “yes” (and see Box 9).

  • Box 12 and 13: “Signature on file” and date of first visit is sufficient.

  • Boxes 14-20: Leave blank.

  • Box 21: Enter diagnosis code(s) according to DSM 5 requirements.

  • Box 22: Only needs to be filled out if you are resubmitting a claim. The code is “7” and the “orginal reference no.” is the one the insurance company assigned on the EOB.

  • Box 23: Typically is left blank, unless you had to get an authorization.

  • Box 24a: Date of service (same in both boxes)

  • Box 24b: Place of service, typically will be “office” which is code “11.”

  • Box 24c: Leave blank

  • Box 24d: CPT code for what type of session you did. “Modifier” is only entered in certain circumstances, for example “HJ” on the claim pictured indicates it was an EAP session.

  • Box 24e: Diagnosis pointer means which diagnosis was addressed/worked on in the session (in this case there is only one so “A” is indicated).

  • Box 24f: The amount you charged (your full fee).

  • Box 24g: Units – in this case one since you did one session.

  • Box 24h: Leave blank.

  • Box 24i: NPI.

  • Box 24j: Enter your NPI#.

  • Box 25: Enter your Tax ID# or SS#. You have to, however, set it up with the insurance company.

  • Box 26: Patient’s Account #. This is a # you assign to the patient, it can be whatever you want it to be.

  • Box 27: Check “yes” if you want the insurance payment sent to you directly. If you want the payment sent to the client check “no”.

  • Box 28: Your total charge (full fee).

  • Box 29: Amount client paid. For example, their co-payment you collected at time of session.

  • Box 30: Leave blank.

  • Box 31: Your signature and credentials (can be typed) and dated.

  • Box 32: Your office name and address.

  • Box 32a: Your NPI# (either group or individual depending on how you are contracted with the insurance company).

  • Box 33: Your name and address or the name of your group and address of the office (again depending on how you are contracted with the insurance company depends what you would put in).

  • Box 33a: Either the group or individual NPI#.


Recent Posts
Search By Tags
Follow Us
  • Facebook Basic Square
  • Twitter Basic Square
  • LinkedIn
bottom of page