CMS-1500 | THE SMART WAY TO PASS | REAL TESTS, REAL RESULTS!

CMS-1500 | THE SMART WAY TO PASS | REAL TESTS, REAL
RESULTS!
CMS-1500 - Answer: used to request payment from health insurance payers, like Medicare,
after a patient has been treated. To fill out the form you must have:

-the patient registration form

-patient health record documentation

-superbill/encounter form



patient registration form - Answer: contains the patient's demographic information and
health insurance payer information. This information must be up to date, and most
practices will institute a policy of verifying the information upon each visit. This form is
usually accompanied by photocopies of the insurance card(s) to ensure accurate spelling,
group numbers, and contact information.



patient health record documentation - Answer: comprised of all of the information
pertaining to the assessment and treatment of the patient. Generally, these will be
separated by encounter.



superbill/encounter form - Answer: This preprinted form is filled out on each visit and
contains the codes that are used in the particular healthcare setting. This form will have
the diagnosis codes and procedure codes designated by the physician at the completion of
the encounter.



How should the CMS-1500 be filled out? - Answer: with all capital letters and no
punctuation



"CARRIER" - Answer: this is where the name and address of the third-party payer handling
the claim will go



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, PATIENT AND INSURED INFORMATION Item 1 - Answer: will require you to identify the type
of health insurance held by the patient. The correct insurance type will be marked with a
capital X



PATIENT AND INSURED INFORMATION Item 1a - Answer: identifying number of the person
who is insured by the policy. This is found on the insurance identification card.



PATIENT AND INSURED INFORMATION Item 2 - Answer: will include the patient's full name:
last name, first name, and middle initial. Only use the punctuation or suffixes (e.g., Jr., III)
exactly as they appear on the patient's insurance card.



PATIENT AND INSURED INFORMATION Item 3 - Answer: contains two fields. The first piece
of information in this field is the patient's date of birth. This must be entered in the MM DD
YYYY format (e.g., 09 22 19XX). There is also a place to indicate whether the patient is male
or female in this field.



PATIENT AND INSURED INFORMATION Item 4 - Answer: requires the insured's name. This is
the name of the insurance policyholder, which may be the same as the patient. If the
insured and the patient are the same person you can write SAME in this box.



PATIENT AND INSURED INFORMATION Item 5 - Answer: patient's full address. It is broken
into spaces for the street address, city, state, zip, and telephone number. Enter these
without any punctuation. Use no spaces or hyphens in the telephone number. The
parentheses for the area code are provided.



PATIENT AND INSURED INFORMATION Item 6 - Answer: indicates what the relationship the
patient is to the policyholder. If the patient is the policyholder, then self would be marked
with an X.




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