Filling out the CMS1500 Claim Form for Insurance Reimbursement

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Submitting your own insurance claim?

See below on information you will need to fill out a 1500 claim form

  1. X “Group Plan”
    1. Insurance ID Number
  2. Patient Name (Last, First, M)
  3. DOB (4 digit year) + Sex
  4. Policy Holder Name (Last, First, M) (same as patient unless held by spouse or parent)
  5. Patient Address
  6. Patient Relationship to Policy Holder 
  7. Policy Holder Address
  8. (leave blank)
  9. (leave blank)
    1. (leave blank)
    2. (leave blank)
    3. (leave blank)
    4. (leave blank)
  10. X “NO” to all three questions
    1. X “NO”
    2. X “NO”
    3. X “NO”
    4. (leave blank)
  11. Insurance Group Number
    1. DOB (4 digit year) + Sex of Policy Holder
    2. (leave blank)
    3. Name of Policy ie “Blue Cross Anthem”
    4. X “NO”
  12. Patient Sign and Date
  13. Patient Sign
  14. Date of Service
  15. (leave blank)
  16. (leave blank)
  17. (leave blank)
  18. (leave blank)
  19. (leave blank)
  20. (leave blank)
  21. Diagnosis Code
  22. (leave blank)
  23. (leave blank)
    1. Start Date and End Date of Service are the SAME date
    2. Place of Service: “11” (office)
    3. (leave blank)
    4. Procedure codes billed: 97110. 97140 (97162 for evaluation) WITH Modifier “GP”
    5. Diagnosis Pointer: should auto-populate with diagnosis codes reflective of “21”
    6. Charges: “$150”
    7. Units: “1”
    8. (leave blank)
    9. (leave blank)
    10. NPI of Physical Therapist
      1. L Barreca Engel: NPI: 1285353359
      2. K Fishkind: NPI: 1720822216
      3. C Fitzgerald: NPI: 1730519448
      4. L Hoyt: NPI: 1912306010
      5. R Jardim: NPI: 1417717893
      6. C Krause: NPI: 1841187051
      7. A McNulty: NPI: 1720638760
  25. Federal Tax ID#: 462093687; X “EIN”
  26. Patient Account Number (generated internally for Custom, nothing to do with insurance), (leave blank if blank)
  27. Accept Assignment “NO” (this indicates reimbursement will go directly to the client versus provider)
  28. Total Charge “$300” for Followup visit
  29. Amount Paid for Followup visit: auto-populates with client payment 
  30. (leave blank)
  31. Provider (PT) and date of service
  32. Custom Performance 295 Madison Avenue New York NY 100177725
    1. NPI: 1316395957
    2. (leave blank)
  33. New York Custom Physical Therapy, P.C. 295 Madison Avenue New York NY 100177725 (212)6827860
    1. NPI: 1316395957

Click here to download a sample CMS-1500 form.

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