If you’ve gone through the process of becoming an in-network provider with a number of insurance companies, then the next step is to learn how to bill insurance payers for your services. While there is a learning curve to insurance billing, the first step to filing an insurance claim starts with a CMS 1500. If you need help organizing claims or insurance billing, Healthie’s Free Starter Plan makes it easy to streamline CMS 1500 forms and payment processing.

In this post we’ll cover what CMS 1500 form basics: what it is, how to file it and how to fill out a CMS 1500 form.

What is a CMS 1500 form?

The CMS 1500 is a health insurance claim form for non-institutionalized healthcare providers, such as private practice nutrition and wellness professionals. If you come from a clinical background,  then this form is like a UB-04. Every single insurance payer, private and federal, requires a CMS 1500 form to be properly completed in order to process the services you provided to your client. Think of it as a way to send an invoice for your services — once it is processed by the insurance payer, you’ll receive reimbursement for your services (if the claim is approved).

You fill out a CMS 1500 each time you wish to submit a claim.

What fields are on a CMS 1500 form?

The main fields on a CMS 1500 form are the following:

1. Payer type of the destination payer.

2. Patient name from patient master.

3. Patient DOB and sex from patient master.

4. Name of the Insured Person of the destination payer in the insurance information screen.

5. Patient address, City, State, Zip code & home phone from patient master.

6. Patient relation to insured of destination payer in insurance information screen.

7. Insured person’s information like address, City, State, Zip code & phone of destination payer in insurance information screen.

8. Patient marital status, employment status & student status from patient master.

What is the difference between CMS 1500 and UB04 forms?

The UB-04 (CMS-1450) form is the claim form used by institutional facilities such as hospitals or outpatient facilities. This would typically include services like surgery, radiology, laboratory, or other facility services. The CMS-1500 form on the other hand, is used to submit charges covered under Medicare Part B.

Below is an example of a CMS 1500 claim form, as well as CMS 1500 instructions. If you are sending the claim form via mail, then you must use forms that have been printed in red ink.

With that being said, most wellness professionals choose the convenience of submitting their claims electronically. E-filing ensures claims are received, and processed, in a more efficient manner, as well as enables better data/financial tracking of claims and payments.

Example of CMS 1500 Form Completed

How to fill out a CMS 1500

The CMS 1500 form requires the following information:

• Client Personal Information: This includes all the basics you would get on an intake form, such as name, date of birth, gender, address, and relationship to the Insured.
• Client Billing Information
• Referral Information: Some insurance companies require that you include any information about the referring provider, like their name NPI number.
• Your Provider Information: This includes your NPI, In-Network Provider ID, and additional information as required by individual company.
• Your practice’s information: You’ll need your location NPI and address.
• Insurance Policy Information
• Diagnosis: Make sure to include all appropriate CPT and ICD-10 codes

Pro Tip: Healthie makes filling out CMS 1500’s a quick task with our in-platform EHR and CMS 1500 form creator. Ask for the information you need from your client during the intake form process and Healthie’s CMS 1500 claim creator will auto-fill each new form after the first time you’ve created it. Healthie’s forms are compatible with clearinghouses such as Office Ally to make filing a claim easier than ever.

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How to file a CMS 1500

Once you have followed our CMS 1500 instructions, you typically will submit it to a clearinghouse. A clearinghouse is a third party company who handles your CMS 1500s and coordinates with the insurance company to pay for your services. Clearinghouses are often digitized nowadays, and tend to act as a central way to keep track of your claims and update you on their status (Healthie is compatible with many top clearinghouses).

If you don’t have a clearinghouse yet, here is a list of popular ones to help get your research started:

1. Office Ally
2. Availity
3. E Claims
4. Payerpath

With your EHR platform, claim generation tool and clearinghouse in place, you’re ready to start submitting CMS 1500 claims to your insurance payer. Claims processing times depend on whether you’ve submitted electronically or via mail, and can vary among insurance companies. In general, your claim can be processed in as little as a few days, to as much as a few weeks.

Now that you’ve learned how to fill out a CMS 1500 claim form? Are you ready to learn more about insurance billing?

Download our free Healthie webinar on Insurance Billing for Dietitians.